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THE NEW SYDENHAM 

SOCIETY. 



INSTITUTED MDCCOLVIIL 



VOLUME CXLVII. 



TptJ^tXos larpos epioTrjdeis, tU av yevvtro riXeios tarpos* 

'O TO. Bwara, efrj, Kai t<x fxi) ^vfaTO. dviufxevos BtayiypwcTKdv. 



lit 



Vet. 14 7 > 

A COLLECTION 



THE PUBLISHED WRITINGS 



WILLIAM WITHEY GULL, Bart., M-D.J.R.S. 



PHYSICIAN TO GUY S HOSPITAL. 



EDITED AND AEEANGED BY 

THEODOEE DYKE ACLAND, M.D., 

PHYSICIAN TO ST. THOMAS'S HOSPITAL. 



MEDICAL PAPERS. 



LONDON: 
THE NEW SYDENHAM SOCIETY. 

MDCCCXCIV. 



R 

117 

^,1 



PREFACE. 



The following papers selected from Sir W. GulFs published 
writings liave been reprinted with only such corrections as 
were absolutely necessary. They have been classified accord- 
ing to the pathological views expressed by the writer, so that 
the paper on "A Cretinoid State '^ (p. 315) will be found 
under Diseases of the Nervous System, and that on " Chronic 
Bright's Disease^' (p. 375) under Diseases of the Vascular 
System. Under the several headings the various articles 
have been arranged in chronological order, so that the pro- 
gressive views of the writer may be traced by reading them 
consecutively. 

The paper on the Effect of Ether on Various Classes of 
Animals (p. 571) is incomplete, but its historical interest is 
so great that it could not rightly have been omitted. No 
record of the original (even if it was ever written) has been 
found. No apology is needed for reprinting the letter on 
Mr. Cock's case (p. 575). It carries the reader back to the 
days when an operation imder the influence of chloroform 
was of such rare occurrence as to be thought worthy of 
special note. 

It is hoped that no paper of importance has been omitted 
from the present volume, but it has been difficult to trace 
writings scattered through current medical literature over a 
period of more than forty years, since no list of them had 
been kept. 

Some of the papers which have been reprinted were 
originally published in collaboration with other writers, and 
this has in each instance been duly acknowledged. 



VI PREFACE. 

The majority of Sir William Gull's lectures on Comparative 
Anatomy, Physiology, and Clinical Medicine were delivered 
from notes only, which accounts for the fact that there is no 
written record of that part of his teaching which occupied so 
large a portion of his early life. 

A Eeport on the Morbid Anatomy, Pathology, and Treat- 
ment of Epidemic Cholera has not been reprinted, as it is 
included in the Reports on Epidemic Cholera issued by the 
Koyal College of Physicians. 

The Addresses will be issued in a subsequent volume 
together with a Biographical Memoir. 

Some difficulty has been encountered in reproducing the 
plates, especially those illustrating the paper " On Changes 
in the Spinal Cord and its Vessels in Arterio-Capillary 
Fibrosis," The original drawings had been lost, but were 
discovered in time to correct the proofs of the reproductions. 
Owing to the efforts of Mr. Newman a satisfactory result 
has been obtained. 

Thanks are due to Mr. Coldrey, late Assistant Librarian to 
the Royal Medical and Chirurgical Society for much valuable 
help, to the editors of various publications for permission 
to reprint the several papers, and to those whose liberality 
has made it possible to issue the present volume in a form 
which it is hoped is not unworthy of the great physician and 
teacher whose life's work it represents. 

T. D. ACLAND. 

March lUli, 1894. 



CONTENTS. 



SECTION I.— DISEASES OF THE NERVOUS SYSTEM. 
(a) DISEASES OF THE BRAIN. 

PAGE 

On Abscess of the Brain . . . . .3 

Abscess of the Brain . . . . -47 

Cases of Aneurism of the Cerebral Vessels . . .86 

(b) DISEASES OF THE SPINAL CORD. 

The Gulstonian Lectures. Delivered at the Royal College of Phy- 
sicians, 1848 : 

Lecture I. — On the Nervous System . . .109 

Lecture II. — Paraplegia . . . .122 

Lecture III. — Cervical Paraplegia — Hemijilegia . .140 

Cases of Paraplegia (Paraplegia from Tumours compressing the Cord) 163 

Cases of Paraplegia. Second Series .... 207 

Cases of Paraplegia associated with Gonorrhoea and Stricture of the 

Urethra ...... 247 

On Paralysis of the Lower Extremities, consequent upon Disease of 

the Bladder and Kidneys (Urinary Paraplegia) . . 254 

Lesion of the Nerves in the Neck and of the Cervical Segments of the 

Cord after " Faucial Diphtheria " .... 274 

Case of Progressive Atrophy of the Muscles of the Hands : Enlarge- 
ment of the Ventricle of the Cord in the Cervical Region, with 
Atrophy of the Grey Matter (Hydromyelus) . -277 

(c) DISEASES IN WHICH SYMPTOMS REFERABLE TO THE 
NERVOUS SYSTEM ARE PREDOMINANT. 

Hypochondriasis ...... 287 

Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica) . . 305 

On a Cretinoid State supervening in Adult Life in Women , . 315 



415 



VUl CONTENTS. 

SECTION 11.— DISEASES OF THE VASCULAR 
SYSTEM. 

PAGE 

On the Pathology of the Morbid State commonly called Chronic 
Bright's Disease with Contracted Kidney (" Arterio-capillary 
Fibrosis") . . . . . ■ '\'2K 

Clinical Lecture on Chronic Bright's Disease with Contracted Kidney 

(Arterio-capillary Fibrosis) .... 37^ 

On Changes in the Spinal Cord and its Vessels in Arterio-capillary 

Fibrosis . . . . . -SOI 

Discussion on the Eelation of Eenal Disease to Disturbances of the 
General Circulation, and to Alterations in the Heart and Blood- 
vessels ...... 

Chronic Nephritis; viz. the Relation between the Changes of Con- 
nective Tissue, Parenchyma, Blood-vessels, and Heart in this 
Disease ...... 422 

Parthenogenetic Tumour attached to the Muscular Tissue of the Left 

Ventricle of the Heart of a Sheep .... 432 

A Case of Intermittent Hpematinuria, with Eemarks . . 435 



SECTION III.— DISEASES OP THE RESPIRATORY 

SYSTEM. 

On Destructive Changes in the Lung from Diseases in the Mediastinum 
invading or compressing the Pueumogastric Nerves and Pulmo- 
nary Plexus ...... 449 



SECTION IV.— DISEASES OF THE DIGESTIVE 
SYSTEM. 

Fatty Stools from Disease of the Mesenteric Glands . .461 

Case of Probable Thrombosis ©f Superior Mesenteric Vein and Renal 

Veins ; Detachment of several Valvula' Conniventes of Jejunum ; 

Recovery ...... 465 



CONTENTS. ix 



SECTION v.— RHEUMATIC FEVER. 

PAGE 

Cases of Rheumatic Fever, treated for the most part bj Mint Water . 475 
Remarks on the Natural History of Rheumatic Fever . -513 



SECTION VI.— DISEASES OF THE SKIN. 

On a certain Affection of the Skin : Vitiligoidea — a. Plana, /3. Tube- 

rosa . . . . . . -Sol 

On the Parasitical Vegetable Nature of Pityriasis Versicolor (Micro- 

spor 011 furfur, Robin) . . . . -561 

On Factitious Urticaria ..... !\66 



SECTION VII.— MISCELLANEOUS PAPERS. 

On the Effects of Ether on the Different Classes of Animals . 571 

Cases of Phlebitis with Pneumonia and Pleurisy from Chronic Disease 

of the Ear ...... 576 



BiBLIOGKAPHT ...... 585 

BiBLIOGEAPHY AEBAXGED IX ChEOXOLOGICAL OedEE . . 593 



LIST OF PLATES. 



FACING 
PLATE PAGE 

I. Illustrating Cases of Paraplegia .... 206 
II. Ditto ditto .... 244 

III. Ditto ditto . . . .246 

IV. Transverse Section of the Spinal Cord at the origin of the 

seventh cervical nerve (Case of G. B — , p. 280), showins; 

Enlargement of Ventricle .... 284 
V. Illustrating Cases of Chronic Bright's Disease with Contracted 

Kidney ...... 372 

VI. Ditto ditto . . .374 

VII — XIX. Illustrating Cases of Changes in the Spinal Cord and its 

Vessels in Arterio-capillary Fibrosis . . .414 

XX. Coils of Valvulas Conniventes passed in the Evacuations in a 

Case of probable Thrombosis of Superior Mesenteric Vein and 

Kenal Veins ..... 470 



LIST OF WOODCUTS. 



PAGE 

Aneurism of left middle Cerebral Arterj . . . 102 

Aneurism of left middle Cerebral Artery . . -104 

Sketch of Capillaries of Spinal Cord incrusted with Oil Globules . 225 

Sketch showing Wasting of Muscles after a blow on the Neck . 232 

Diagram of Spinal Cord showing Enlai-gement of Ventricle . 281 

Portraits illustrative of Cases of Anorexia Nervosa . . 306 

Ditto ditto . . 308 

Ditto ditto . . 312,313 
S'ketch oi. the Microsiwron furfur .... 562 



SECTION I. 

DISEASES OF THE NERVOUS 
SYSTEM. 



(«) DISEASES OF THE BEAIN. 



ON ABSCESS or THE BEAINJ 



The brain exhibits in disease a tendency to suppuration 
wbich gives it a pathological rank with glandular organs. 
The bearing of this upon the therapeutics of cerebral affec- 
tions in general, is both obvious and important, especially as 
to the use of mercury, since it is admitted that the diseases 
of tissues having this predisposition, do not bear the full 
action of that remedy. 

A recent excellent writer^ admits the occurrence of idio- 
pathic cerebral abscess. I suppose he means no more than 
abscess whose origin is unaccounted for, since we have no 
evidence of any such intrinsic perversion of the nutrition of 
the brain as leads to suppuration. The nearest approach to 
such a result is in scrofulosis, but then only where the 
scrofulous deposit acts as an extraneous substance upon the 
tissue in the same manner as an hydatid cyst ; in neither of 
which cases can the suppuration be considered idiopathic.^ 
A perusal of the cases given by Abercrombie may have 
favored the opinion referred to, as he seems tacitly to assume 
an independent origin in many of them. But it is to be re- 
membered, in contradiction to such an inference, that the 
cases he records are principally intended to estabish the fact 
of suppuration, the different forms of it and its general sym- 
ptoms, and not avowedly to trace the causes. This of neces- 
sity is a later subject of inquiry. 

It is in, what has been called, " metastatic abscess,'^ that 

1 Reprinted from the ' Guy's Hospital Eeports,' vol. iii, 1857, p. 261. 

" Lebert, " Uber Gehimabscesse," ' Archiv fiir pathologische Anatomie,' 
&c., Bd. X, 1856. 

^ The distinction here insisted upon is obviously more than a verbal 
refinement. Daily experience proves how much clinical investigation is pre- 
vented by the inappropriate use of the word idiopathic. 



4 DISEASES OF THE NERVOUS SYSTEM. 

the causes are apt to be overlooked. The suppuration in the 
brain often appears as an isolated affection^ and the local 
disease which gives rise to it is regarded as a mere coin- 
cidence. It is, indeed, only by multiplied examples that we 
can get to see the relation between the primary disease and 
the secondary effects. For instance, Abercrombie records 
the case of a gentleman who for years had been subject to 
cough and purulent expectoration, with cirrhosis of the 
lung, and who died of secondary abscesses in the brain. The 
connection between the disease in the chest and in the brain 
would, from this one case, appear only as a coincidence, but 
taken with Cases 12, 13, 14, (36, 3 7, 38)^ given below, we should 
be prepared at the bed-side for a recurrence of the pheno- 
mena. These cases of secondary abscess are amongst the 
most obscure, whether we regard their insidious origin and 
latent course, or the primary diseases which give rise to them. 
The brain is especially liable thus to suffer, and in instances 
where the liver and lungs are unaffected. It was so in Case 9 
(33), where ileitis set up abscess of a mesenteric gland, which 
in its turn was the cause of many secondary abscesses in the 
brain, and in Case 8 (32) chronic abscesses of the abdominal 
wall was followed by several abscesses in the brain, though 
the other viscera escaped. Case 9 (33) is the more striking 
since, according to our present theories of purulent infection, 
the capillaries of the liver ought to have suffered first. , When 
the primary abscess is at a distance, the blood appears 
to be the only medium through which the moi'bid influence 
can be conveyed, but the steps of the process are not yet clear. 
Although we have used the word "metastatic/' we cannot 
admit the validity of the theory in the present subject. We 
have no evidence that a distant tissue begins to suppurate 
by some mysterious transference of foixe, like the sinking 
of one end of a balance when the weight is lessened at the 
other. Something of this kind may occur in the natural 
functions and growth of parts, but it is probably limited to 
the processes of nutrition under the regulation of the reflex 
working of the sympathetic system, and does not extend to 

^ The numbers in brackets throughout this paper refer to a table of 
symptoms and causes of abscess of the brain reprinted from ' Reynold's 
System of Medicine,' see pp. 65 — 84. Ed. 



ABSCESS OP THE BRAIN. 5 

such wide perversions as the formation of pus. The theory 
of the transmission of the morbid action through the cerebro- 
spinal nerves which some have endeavoured to establish by 
such instances^ as the removal of a testis, followed by abscess 
in the opposite lobe of the cerebellum, is equally untenable, 
these cases being in all probability examples of secondary 
abscess through the blood, the seat of which is accidental. 

With this tendency to secondary suppuration in the brain 
is also to be noted the fact of its latency. A person may per- 
form all his duties and be in apparently good health, though 
for many months he may have a large abscess in the cerebrum. 
Case 13 (37) is a remarkable illustration of this. The patient 
was even amused by the involuntary jerkings of the arm 
which ushered in the fatal inflammation around the cyst. 

The latency of cerebral abscess seems explicable by the 
combination of several facts. It is generally seated in the 
substance of the hemispheres, where it is known that exten- 
sive disorganisation may go on without any indication, 
provided the corpora sti-iata, thalami optici, and other 
central parts be not involved ; the cerebrum and cerebellum 
appearing to have, like other organs, a surplusage not 
required on ordinary occasions. 

Encysted abscess probably forms slowly, and does not so 
much destroy as compress parts, and when the compression 
is gradual and uniform there is a yielding which, up to a 
certain point, is compatible with function. 

In many instances even at last it is not the abscess itself 
which occasions the symptoms, but the reactive inflammation 
around it. 

The course of cerebral abscess is in our present experience 
always a fatal one. There are no known cases where the 
sac has contracted, and the pus dried up, as occasionally 
happens with chronic abscess in other parts. " At first 
sight," says Lebert, "it may appear remarkable that, with 
so frequent encysting of the abscess, and with a latent course, 
often of many months, no instance of real cure should be 
known, whilst in softening and effusions of blood the for- 
mation of a cyst is the first step in the healing process. 
The cyst which surrounds the abscess is, however, altogether 
different from those mentioned. It is thicker, more 



6 DISEASES OF THE NERVOUS SYSTEM 

vascular, and partakes of the quality whicli pyogenic 
membranes have of pouring out pus, so that instead of being 
absorbed, the quantity is increased, the pressure on the 
brain heightened, and the way prepared for an unfavorable 
course as well as a fatal termination." 

We can hardly admit that the structure of the cyst is 
alone the cause of the unfavorable issue, since there is 
nothing in it different from that of chronic abscesses in 
general, which occasionally do contract and dry up. In 
Case 14 (38) the pus was actually beginning to undergo the 
earthy infiltration indicative of such a process. It is 
probably rather to other circumstances than this that we 
must refer the fatal result. The pus of cerebral abscess is 
prone to undergo decomposition. All observers have 
noticed the occasional fetor of these collections, quite apart 
from any communication with bone or the external air. In 
this occurrence, and in the extreme alkalinity and mucoid 
character of the pus, which is so frequent in these cases, we 
cannot but recognise chemical peculiarities which oppose 
that quiescence of capillary action necessary to the process of 
cure. The surrounding tissue also, after much stretching, 
becomes inflamed, and so brings on a fatal termination. 

The direction in which cerebral abscess extends is fre- 
quently in itself also a fatal one. Following the line of 
least resistance, it slowly approaches the cavity of the 
lateral ventricles, into which there is at last a rupture. 
This accident may give rise to the earliest acute symptoms 
indicative of important disease of the brain, and then the 
case may be singularly perplexing. 

In contrast to the insidious course of the disease when 
the abscess is encysted, are some instances of acute suppu- 
ration, and often sloughing where the brain becomes 
involved by extension of disease from the ear, or when the 
inflammation is secondary to chronic disease of the nose as 
in Cases 2 (26) and 4 (28). 

There is a form of the malady where in the early stage 
the symptoms are not altogether unlike those of continued 
fever. After the febrile state has lasted for some time 
there may be apparent convalescence, in which either slowly 
or suddenly the final cerebral symptoms show themselves. 



ABSCESS OF THE BRAIN. 7 

These different phases of the case probably correspond to 
certain stages of the disease going on in the brain ; — the 
onset of the inflammatory action ; — the gradual process of 
encysting ; — and, lastly, the reactive inflammation from 
distension of the surrounding tissues. Case 1 1 (35) may be 
adduced as an illustration. 

The details of the structure of the cyst are appended to 
Cases 12 (36) and 14 (38), 

Lebert speaks of the granular character of the pus in 
cerebral abscess and of the small number of typical cells it 
contains. Similar observations were made in Case 8 (32). 
Such peculiarities are not noticed where the suppuration is 
recent, and are probably the result of secondary changes in 
the contents of the abscess. The same author in the 
article referred to, also notices the fact that abscess 
generally forms in the white substance, rarely in the gray, 
though the latter is the more vascular. This is confirmed 
by all experience. 

The time within which a cyst may form in the brain is 
shown in the following case, which lately occurred under 
the care of my colleague, Mr. Birkett. A boy, aet. 14, 
whilst working in a factory received a backhanded blow 
from a hammer, causing compound fracture of the skull. 
He lay a day or two insensible, and then slowly recovered 
consciousness. On the sixth day from the accident, there 
was spasmodic twitching of the right side of the face, and 
loss of the use of the right arm. He was bled with relief, 
and two days after could grasp with the hand, but some 
degree of paralysis of the right side remained. At the end 
of three weeks the wound had progressed favorably and 
was nearly healed, but the boy was in a listless state. At 
the beginning of the fifth week he began to vomit his food, 
and complained of pain in the head. These symptoms were 
soon followed by drowsiness without any marked paralysis. 
He seldom spoke, but took food readily, seeming to live as 
a mere vegetable. He died eleven weeks from the accident. 
For the post-mortem details I am indebted to Dr. Wilks's 
report. Anterior to the point of injury, so that a trochar 
passed in would not have reached it, was an encysted 
abscess, containing about an ounce and half of pus of the 



8 DISEASES OP THE NERVOUS SYSTEM. 

usual cliaracter but not fetid. The cyst was an eighth of 
an inch thick, of a fibro- cellular structure, and so strong 
that by placing the finger in its cavity it was supported 
entire, whilst the brain-substance fell from it. The 
surrounding portions of the anterior and middle lobes were 
gray and ochrey, and contained abundance of granule-cells. 
The cyst was surrounded on all sides to the thickness of an 
inch by the cerebral substance. Considering the youth and 
previous health of the patient, it is probable we have here 
a fair limit, at least in one direction, of the time necessary 
for the formation of such a cyst. The shortest period we 
can infer from it is seven weeks, it was probably nearer ten. 
The subject has a special value in etiology, since proof of 
the duration of an abscess may indirectly become proof 
of its cause, as may be shown in the following examples : 
In Case 12 (36), a girl who had long been the subject of 
chronic suppuration in the chest, sickened with variola on the 
27th January. On the i6th February she was convalescing 
favorably. On the 17th she became delirious and 
comatose, and died on the 22nd, with several encysted 
abscesses in the brain ; the walls of the cysts being strong 
and vascular. It was a question whether these abscesses 
wore the result of pyaemia, set up during the maturation 
of the variolous pustules, or secondary to the chest affec- 
tion. The organisation of the cysts negatived the former 
assumption, since it was not probable such structures could 
develop within fourteen days. Case 4 (28) is a converse 
instance. The patient had a severe fall from a carriage a 
year and a half before his death ; he had also had polypus 
nasi for some time, and was exposed to severe cold just 
previous to the onset of the cerebral symptoms. There was 
no trace of a cyst, but the brain-tissue which surrounded 
the pus was softened and vascular, as in acute inflammation. 
Opinions were divided as to the cause of the abscess, 
whether it was due to the fall or to the chronic disease of 
the nasal mucous membrane. The absence of any limiting 
wall to the abscess, and the condition of the brain-tissue 
around, entirely forbad the supposition that it had been so 
long latent as a year and a half. On the contrary, taken 
in connection with the recent exudation over the sella 



ABSCESS OF THE BRAIN. 9 

turcica^ these conditions were decidedly indicative of its 
relation to the disease in the nose. The medico-legal 
bearings of the subject are obvious. Lebert gives the 
following details.^ After stating that the duration of acute 
abscess is from three to twenty-four days, lie says, 
" Lallemand asserts that in one instance he found a soft 
limiting membrane as early as the thirteenth day. In two 
cases it was from the twenty-second to the twenty-fourth 
day, so that we may place the beginning of the formation 
of a cyst about the third and fourth week. The greatest 
number are found between the thirtieth and sixtieth days, 
in the following proportion : In two-thirds of the collected 
cases which could be used in the calculation two had a 
duration of thirty-two days ; one of thirty-five days ; one of 
thirty-seven days ; two of forty-two days ; one of fifty days ; 
one of fifty-three days ; one of fifty-five days ; and thi-ee 
of sixty days. Within this period firm, organised cysts 
were met with, and the later the period the more readily 
were they separated from the surrounding brain-substance. 
There were lastly two cases in the third month, one of 
seventy-five days^ and one of ninety days' duration. And 
last of all a case which lasted 105 days.^' To this last may 
be added Case 13 (37), where eight months probably elapsed 
between the origin and final issue of the case. The con- 
ditions under which cerebral abscess occurs would lead us 
to anticipate great variety in its symptoms. We have seen 
that the disease may be from the beginning acute and 
rapidly progressive. In such cases the symptoms have for 
the most part a corresponding intensity. The most sticking 
examples arise, as before-mentioned, from chronic disease of 
the ear or of the nose, in otherwise healthy subjects. Head- 
ache, often intolerably severe, is the most prominent feature. 
'^ I never wished so much to be well as I now do,'' said a 
strong man in the agony of his sufferings in one of these 
cases (Case 4 (28) ). The headache is generally frontal, fre- 
quently more severe over the brow on the side of the abscess, 
but in this there is no uniformity. It is remarkable that, 
though there may be acute abscess, and sloughing brain 
and dura mater over an extensively carious temporal bone, 
* Op. citat., p. 100. 



10 DISEASES OF THE NERVOUS SYSTEM. 

yet the patient may make no such complaint of local pain 
as to draw attention to the source of the disease. No doubt 
many cases from beginning to end are from this cause 
involved in obscurity. In 1853, Henry D — , eet. 25, was 
admitted under my care into the clinical ward, suffering 
with intense frontal headache, which he attributed to 
anxiety and sleepless nights. The pupils were natural. 
Respiration 28. Pulse 76. Tongue rather dry, with 
brownish fur in the centre. Bowels regular. There was 
no heat of the head nor any injection of the conjunctiva. 
He moved all his limbs freely. For three days there was 
no other symptom of cerebral disease, but the intense pain 
in the forehead. He denied that it was more on one side 
than the other. On the fourth day there was transient 
delirium, and an occasional effort to vomit. At 4 p.m., on 
the sixth day, the patient died suddenly and unexpectedly. 
On the superior part of the right petrous bone, the dura 
mater was destroyed by sloughing, over a large carious 
opening in the roof of the tympanum. In the adjacent part 
of the middle lobe of the brain, there was an abscess con- 
taining two ounces of fetid pus. It extended inwards to 
the descending corner of the lateral ventricle. The brain- 
tissue around was yellowish, ecchymosed, and softened. 
It was a matter of surprise to all who saw the case that, 
with such extensive local injury, beginning from the 
coverings of the brain, the patient should have made no 
complaint of pain at the part, but should have referred all 
his sufferings to the forehead. 

In some acute cases a convulsion marks the onset of the 
inflammatory process. 

The frequent latenc}' of the disease and the causes which 
favour such a course have been alluded to. There may be 
absolutely no symptoms, and the abscess be only accidentally 
discovered after the death of the patient from some other 
cause. This latency, as before remarked, is for the most 
part only up to a certain point, and then the symptoms 
attending the accidents of the abscess are suddenly or slowly 
produced. These vary with the changes in the nervous sub- 
stance. A local spasm or convulsion ; a repetition of con- 
vulsions ending in paralysis with or without insensibility ; 



ABSCESS OF THE BRAIN. 



11 



sudden paralysis Avithout convulsion ; drowsiness gradually 
increasing to stupor and coma, are some of the varieties. 

The beginning of the symptoms from ruptnre of the 
abscess into the lateral ventricles has been noticed. 

The attendant headache differs from the headache of 
tumour in being less paroxysmal, and of shorter duration 
before complications occur with it. The difference of this 
symptom in the two diseases, tumour and abscess, is to be 
viewed in relation to the different seats of the two lesions, 
a,nd to their secondary influence on the brain- tissues, A 
large proportion of tumours arise in the bones and mem- 
branes. Abscess, on the contrary, principally affects the 
medullary substance of the brain. This is shown by a com- 
parison of the following tables : that of the seat of tumours 
is from Lebert;^ the other includes cases of abscess from 
Abercrombie and Lebert, and those subjoined by myself, 
excluding from the list the cases of abscess depending upon 
disease in the ear or in the nose or on other local causes 
which might determine its site. 



Origin of Tumours Greeting the Brain and 


its Membranes. 


(Lebert.) 
A. Single Tumoijes — 




I. Beginning in the bones 


3 


2. Beginning in the membranes — 




Convex surface .... 
Base ..... 


• 131 

22 ' ^ 
MO 
3 


Falx cerebri .... 


Tentorium cerebelli 


. 2J 


3. Cerebral substance — 




Convex surface of the hemispheres 
Deep parts of the hemispheres . 
Protuberance and medulla oblongata 
Cerebellum .... 


4| 
8 {.36 

• 41 


Pituitary gland .... 
B. Many Tumoues — 


• 3^ 


Bones only ..... 
Membranes only .... 


2- 

2 


Cerebral substance only 


6 y 15 


Bones and membranes 


• H 


Membranes and cerebral substance . 


• 3^- 




94 



' " Ueber Krebs und die mit Krebs verwechselten Geschwiilste im Gehim 
und seinen Hiillen," ' Archiv fiir Pathologische Anatomic,' &c., Bd. iii, 475. 



12 DISEASES or THE NERVOUS SYSTEM. 

Seat of Cerebral Abscess not depending upon Disease of the 
Ear or other parts adjacent to the Brain. 



In medullaiy substance of tlie hemispheres 

In C0115US striatum 

In optic thalamus and posterior lobe 

In medulla oblongata with scrofulous deposit 

In cerebellum .... 



15 
2 
I 
I 
I 



It Avill be thus seen that iu ninety-one cases of tumour 
(excluding the three cases of tumour of the pituitary gland), 
the bones or membranes were in fifty-two implicated from 
the outset of the disease, and that in ten at most was the 
tumour limited to the deeper parts of the hemispheres. 
Abscess, on the contrary, is very rare between the mem- 
branes, and then only when it arises from local disease of 
the bone, whilst in fifteen out of twenty cases it was seated 
in the substance of the hemispheres. It is obvious why, in 
such an estimate as this, the cases of abscess from diseases 
of the ear, which are so common, should be excluded ; for, 
although in some cases as remarked below, the abscess of 
the brain which follows is less from contiguity than fi'om 
secondary processes, which operate at a distance, still it is 
difficult in these cases to exclude localising influences. It 
is necessary thus to explain, or it might be a matter of 
surprise that the above table was so limited in its numbers. 

The chronic and neuralgic character of the headache in 
tumour may be in part due to the inequality of its growth 
as well as to its seat. Abscess would produce a gradual 
and uniform pressure, which tumour would not. 

When a patient is debilitated, the symptoms of suppura- 
tion of the brain may be as it were stifled in the general 
oppression of the nervous system, and the only notice of 
cerebral lesion, may be paralysis (often accidentally dis- 
covered), or the occurrence of a gradually deepening coma. 

The cases of suppuration in the brain which in their 
general aspect, simulate continued fever, present, on a 
nearer scrutiny, many distinctive differences, such as occa- 
sional vomiting, constipation, contracted abdomen, vertigo, 
headache, more continued and severe than in fever ; a slow. 



ABSCESS OF THE BEAIN. 13 

full, and sometimes intermittent pulse ; impatience of dis- 
turbance, &c. 

For the diagnosis of cerebral abscess it is obvious that 
we cannot hope to find any pathognomonic symptom . Whether 
the brain-tissue suffer from tumour or abscess, or be other- 
wise compressed and disorganised, we may in turn, and in 
different cases, expect to have headache, convulsion, drowsi- 
ness, paralysis, and coma. Such symptoms considered 
individually, or as one may say statistically, avail but little 
in determining the conditions which give rise to them, no 
more indeed than an enumeration of the letters and words 
of an inscription, towards its decipherment. It is their 
order and duration which gives them their characteristic 
importance. 

The headache of abscess is different both in character and 
duration from that symptomatic of tumour. It is rarely 
paroxysmal and neuralgic, as it is in tumour, but more 
general and uniform in its expression, as well as more sudden 
in its rise and acute in its progress. Tumours, as we have 
seen, frequently affect the membranes, and often have a 
long chronic course ; at the onset the pain is also more 
limited, or takes the course of particular lines of nervous 
distribution. 

Our knowledge of the seat and character of such growths 
no doubt helps us to appreciate better these degrees of 
difference, which, like different accents on a word, give a 
variety of meanings to the same symptom. 

General convulsion with insensibility is in itself of but 
little value in the diagnosis of any brain disease. In abscess 
it probably occurs only at two stages : at the onset of acute 
changes in the nervous tissue, especially if such changes 
begin in the vicinity of the membranes ; and at a later 
period, if the abscess bursts inwards into the lateral ven- 
tricle, or extends outwards to the surface. Amongst the 
subjoined cases is one where the abscess formed between 
the membranes under the posterior lobe of the right hemi- 
sphere. There convulsions occurred early. 

Limited convulsion without insensibility has far greater 
value, not as being absolutely distinctive, since the same 
often occurs with tumour, but as being to a great extent 



14 DISEASES OP THE NiiRVOUS SYSTEM. 

indicative of local disease ; the character of which is to be 
determined by concomitant conditions and by the other sym- 
ptoms. Case 13 (37) is such an instance, the clonic convul- 
sion of the right arm without any affection of the conscious- 
ness, viewed in relation to the chronic suppuration in the 
chest, was an indication upon which the diagnosis was made 
of the presence of abscess in the brain. Abercrombie has 
described the remarkable course of these cases : the local 
clonic spasm without insensibility ; the gradual supervention 
of epileptiform convulsion ; the paralysis which follows 
indicating extension of irritation and pressure, more rapid 
in their course in abscess than in tumour. 

Though convulsion may be the first symptom of both 
tumour and abscess, there is generally this difference in the 
course of the two diseases ; after convulsion with abscess, 
the recovery is more or less imperfect, and the patient re- 
mains drowsy and oppressed ; whilst with tumour, on the 
contrary, there may be epileptiform convulsions for a con- 
siderable time, the patient in the intervals of the seizures 
recovering almost, if not quite, his usual health. 

The pathological order of the symptoms in abscess, as de- 
duced from observation, is headache, local or general con- 
vulsion, drowsiness, paralysis, coma. As might have been 
anticipated, there is no such constancy in the presence or 
intensity of these phenomena as to make them unequivocal 
in their indication ; and hence, at the bedside, it is often 
only by collateral circumstances, and by the known associa- 
tions of the malady, that we are able to complete the 
diagnosis. 

If it be true, as I believe it is, that with the exception of 
suppuration produced by scrofulous deposit, idiopathic abscess 
of the brain does not occur, and that, with the exception of 
that which follows direct injury, it is a secondary result of 
the suppurative process in some distant part, or of chronic 
disease about the head, then it is obvious that a scrutiny of 
every organ is the first step in the diagnosis, or that at least 
without which the diagnosis cannot be completed. It may 
often be difiicult to trace the suppurative tendency to its 
source. In one of the cases given below nothing could be 
more obscure during life, and after death it was only with 



ABSCESS OF THE BRAIN. 15 

some labour that it was ultimately made out to be dependent 
upon chronic suppuration of the mesenteric glands from 
ileitis in a debilitated subject. In a case given by Dr. 
Bright, whitlow was the source of general pyaemia and 
abscess of the brain. In another case referred to by Lebert, 
the drawing of a tooth was the first step towards the morbid 
process. This was followed by inflammation of the upper 
jaw, ophthalmia, and acute cerebral abscess.^ 

The general symptoms attendant upon the formation and 
presence of abscess in the brain occur equally in hydro- 
cephalus. In both diseases, acute changes may be going 
on within the cranium, though the head and extremities 
remain cool. The altered respiratory rhythm ; the slow, 
occasionally intermittent, pulse ; sluggish pupils ; vomiting 
and constipation are evidence only of an oppressed medulla 
oblongata, which may arise from many causes. 

Rigors are not amongst the constant symptoms. They 
appear to be more frequent in inflammation of the lateral 
sinus, or when pus collects between the dura mater and 
bone. The nervous tissue yields readily, and hence, pro- 
bably, the tension which excites rigor is not commonly 
produced by the formation of pus in its substance. 

Our present knowledge of therapeutics leaves us hopeless 
when suppuration has already taken place in the brain. 
The practical lesson of a large number of these cases is 
little more than priiicipiis obsta. There is no doubt a bad 
and a good treatment in the most desperate cases. Could 
we be sure of the existence of abscess, or of the acute or 
chronic processes leading to it, our treatment would cer- 
tainly often be very different from that commonly resorted 
to. Diagnosis must, however, improve before much can be 
attempted, and even when our insight shall have become 
perfect, the peculiarly unfavorable conditions of the disease 
will remain. 

There are no sure criteria of the seat of the suppuration 
even whilst there is the strongest probability of its exist- 

^ A table, originally inserted here, of the principle symptoms and causes 
in the sixteen cases of abscess of the brain, recorded in detail in this paper 
(p. 17 seq.), has been omitted, as it is included in the article written for 
Reynold's ' System of Medicine,' see pp. 65 — 84, Nos. 25 — 40. Ed. 



16 DISEASES OF THE NERVOUS SYSTEM. 

ence. The following cases, and the recorded experience of 
others, show that there may be pain in the forehead, with 
abscess in the cerebellum, pain in one side of the head, 
whilst the abscess is in the other hemisphere, and even no 
symptom but drowsiness, though suppuration is extensive. 
The not unfrequent occurrence of more than one abscess is 
also a further complication of the diagnosis. Even where 
abscess follows injury to the scalp, it is not so entirely 
under the external wound as to make us sure of evacuating 
the pus by an incision. Clinical experience shows, how- 
ever, that the brain-tissue will bear more mechanical inter- 
ference than might have been supposed, and encourages the 
hope that as knowledge increases even here, our power may 
increase with it. Detmold's case,^ notorious from the 

' The following is an abstract o£ this remarkable case. A healthy man, 
forty years of age, received, on July 14th, 1849, ^ severe blow from a piece 
of machinery, causing compound fracture of the left frontal bone. He went 
on well for three weeks, when symptoms indicating pressure came on. 
These were relieved by removing some pieces of loose bone from the wound. 
Nine weeks after the accident he complained of headache and became 
drowsy. The following day he was in a profound stupor, from which 
nothing could rouse him. Pulse slow ; pupils fixed. An abscess was sus- 
pected. Some fragments of bone were removed without any improvement 
of the symptoms. It was then that Dr. Detmold determined to attempt 
evacuating the pus. On the 13th of September, the cicatrices which had 
formed over the wound and dura mater adherent to it, were dissected oflE, 
and an incision made into the brain beneath, an inch in length and an inch 
and half in depth. A large quantity of pus flowed out, variously estimated 
by those present at from two to five ounces. The patient at once recovered 
consciousness, and answered distinctly that he felt better. The pulse rose 
from 40 to 60 in the minute. The exposed part of the brain cicatrised, and 
the patient was able to leave his bed on the eighteenth day after the opera- 
tion. Three weeks after the operation he began to lose his memory. On 
the 1 8th of October, the part from which the bone had been removed had 
sunk in considerably, encouraging the hope that the cavity of the abscess 
was closing. There was at this time a return of headache and a slight con- 
vulsion. On October 22nd, as stupor had again come on, another incision 
was made into the brain to the depth of an inch and a quarter without any 
pus being found. The next day a probe was introduced, and to the astonish- 
ment of the operator passed four and a half inches deep in the direction of 
the lateral ventricle, indicating that the abscess had opened into that cavity. 
After this the patient mended bodily, but entirely lost his memory. It was 
determined, as a last effort to save him, to lay open the lateral ventricle 
itself by an incision. This was done, and half an ounce of pus flowed 



ABSCESS OF THE BRAIN. 17 

doubts as to its veracity and the subsequent testimony^ to 
its truth is a striking- illustration. Though life was not 
ultimately saved, it was prolonged by the surgical inter- 
ference, and for a time consciousness and reason were quite 
restored. It might be of the highest importance in a 
similar case if only this could be effected. 

According to Lebert, there is no recorded case of cere- 
bral abscess undergoing the process of cure. It is not 
improbable that, apart from the fatal tendencies of the 
malady, the prevalent use of mercui'ials, as remarked upon 
at the beginning of this paper, may have had its share in 
this unfavorable history. 

Case I (25) is given at page 10. 

Case 2 (26).— Polypoid growth from inner wall of tympanum ; destruction 
of membrana tympani ; caries of petrous bone ; sloughing of the inferior 
half of the middle lobe of cerebrum. 

Sarah C — , set. 23, a healthy young woman, employed as a domestic ser- 
vant, had occasional discharge from the right ear from three years and a half 
old, and was deaf on the same side, but as far as could be ascertained the 
deafness was not constant. Fourteen days before her death she began to 
complain of intense pain in the head, and had frequent sickness. She con- 
tinued, however, to do her work until the i8th of April, 1857, when she 
came under the care of Mr. Stedman, through whose kindness I had the 
opportunity of examining the brain. The pain was then on the right side of 
the head and in the right ear, from which there was a purulent discharge- 
The pulse was slow and labouring. Her mind quite collected. The follow- 
ing day the symptoms were unchanged. On the 20th she had paroxysms of 
extreme restlessness and violent sci-eaming, crying out " Oh, my head !" 
There was great cerebral oppression at times, but up to the morning of the 
22nd, the day of her death, she protruded her tongue when asked to do so, 
and could speak distinctly. There was no convulsion nor hemiplegia. The 
pupils were dilated, but unequally so. 

Post-mortem examination. — Thoracic and abdominal viscera perfectly 
healthy ; no trace of tubercles. The inferior half of the middle lobe of 
cere Drum on right side sloughing, ash-coloured, and intolerably offensive. 
The sloughing extended into the descending comu of the lateral ventricle, 

out. The patient died the same evening, seven weeks after the first opening of 
the abscess. On a post-mortem examination, both lateral ventricles were 
found to contain pus— the right a larger quantity than the left, this cavity 
having been in part emptied by the incision made into it before death. The 
incision had been can-ied into the roof of the anterior corau. ' American 
Journal of Med. Science,' January, 1850. 

1 ' Archiv fiir Pathologische Anat. und Physiol.,' 1857. 

2 



18 DISEASES OF THE NERVOUS SYSTEM. 

and afFected the body of the fornix. The thalamus and corpus striatum were 
superficially of an ash-grey colour, and softened. A thin offensive purulent 
fluid infiltrated the sloughing tissue, and was effused into the ventricles ; 
the choroid plexus of the fourth being sodden and discoloured by it. Cere- 
brum healthy. The dura mater covering the roof of the tympanum, and in 
the situation of the lateral sinus, ash-coloured and offensive, but not per- 
forated. Between it and the bone fibrinous exiidation. The lateral sinus 
contained partially disorganised clots. The roof of the tympanum was de- 
stroyed by caries to the extent of a silver threepence, including a large part 
of the superior semicircular canal. The vestibule and semicircular canals 
contained pus. The cavity of the tympanum was filled with a soft cream- 
like pulp, which, on microscopic examination, consisted of granular matter, 
oil-globules, crystals of ammoniaco-magnesiau phosphate, and fine acicular 
fatty crystals. The stapes was in situ. A polypoid growth attached by a 
narrow pedicle to the promontory, obstructed the auditory canal. It was 
fibro-nuclear in structure. I am indebted to my friend, Mr. James Hinton, 
for the dissection of the ear. 

Remarks. — If Louis's induction be of value^ the absence 
of tubercles from the lungs was in itself evidence against 
the tubercular character of the disease of the ear in this 
case. The healthy condition of the thoracic and abdominal 
viscera, contrasted remarkably with the fearful ravages of 
the sloughing process in the brain, which had been set up 
by the contact of the dead and partially decomposed dura 
mater lying upon carious bone. The obstruction of the 
external meatus by the polypus appears to have been the 
immediate cause of the retention of the exudation in the 
tympanum, and thus indirectly of this destructive process. 
Considering the healthy character of the patient in all 
respects, except the disease of the ear, there is great pro- 
bability that suitable local treatment would have entirely 
obviated the course of the malady. 

Case 3 (27). — Inflammation of mucous membrane of tympanum ; caries of 
the chain of bones ; displacement of stapes ; caries of wall of meatus 
auditorius internus ; inflammatory softening of trunhs of auditory 
and facial nerves ; abscess of cerebellum by extension of inflammation 
through the vein of the aquxductus vestibuli. 

Anna W — , aet. 20, was admitted into Guy's Hospital under the care of 
Mr. Cooper Forster, December 31st, 1856, for primary sore, ulcerating con- 
dylomata, and vaginitis. It was also observed that she had paralysis of the 
right facial nerve, of which she gave the following account : — " Three weeks 
ago one of her companions gave her a severe blow with the hand on the 



ABSCESS OF THE BRAIN. 19 

right side of the head. This was followed by discharge from the ear, and a 
week ago the face became paralysed." On repeated questioning she denied 
that she had anything the matter with the ear before receiving the blow. 
For the first few days after admission her syphilitic symptoms arrested most 
attention, but on the nth January she began to complain of more severe 
pain in the forehead, extending to the occiput and upper part of the neck. 
The pain was much increased by rotating the head. She lay on the right 
side with her head firmly pressed between her hands. No delirium. Com- 
plained of vertigo and nausea. Frequently vomited. The day previous she 
had a decided rigor followed by sweating, and since that time frequent chills 
and heats. Face and head and extremities cold. Pulse 56, extremely small 
and feeble, and slightly irregular. No throbbing of carotids. Abdomen 
collapsed. Constipation. Fetid purulent discharge from right ear. She 
was treated by leeches and saline purgatives, and the two following days her 
symptoms remained the same. There was no delirium nor unconsciousness. 
Frequent moaning complaint of pain in the head, from the forehead to the 
occiput, and at the back of the neck. There were still frequent heats and 
chills, and once in the twenty-four hours a sharp rigor and sweating. The 
pulse remained about 60. Eespiration 20, varing in depth and frequency. 
Early on the morning of the 14th she was taken with convulsive sobbing, 
without unconsciousness ; this lasted for an hour or more, when she became 
pale, and died without a struggle. 

Post-mortem examination. — Membranes and hemispheres of cerebrum 
healthy. In right lobe of cerebellum, near the surface, an abscess containing 
about six drachms of greenish mucoid pus, not fetid. The superficial wall of 
the abscess was adherent to the dura mater for a small space, corresponding 
to the entrance of the vein from the aqueductus vestibuli. The abscess was 
limited by a highly vascular cyst. The surrounding nervous substance was 
oedematous, with a few scattered exudation corpuscles amongst the loosened 
fibres (inflammatory oedema). The body of the fornix was difiluent and 
ecchymosed. The lateral ventricles contained four drachms of slightly 
opalescent fluid. The lateral sinus contained adherent coagula. Both por- 
tions of the seventh nerve were soft, and contained exudation corpuscles. 
There was also slight ecchymosis at the origin of the portio mollis in the 
floor of the fourth ventricle. The inflammation of the nerve-trunks had 
probably arisen in pari by extension along the sheath, from the internal 
meatus, and in part from contiguity with the abscess which lay over their 
course. The membrana tympaui in part destroyed. The handle of the 
malleus separated from the body of the bone by caries ; the base of the 
stapes extensively carious and displaced from the fenestra. The semicircular 
canals contained a bloody fluid, but the petrous bone was not examined 
in a sufiiciently recent state to admit of an exact account of the 
contents of the labyrinth. The wall of the meatus auditorius internus 
carious ; a deposit of new bone on the upper and posterior wall of external 
meatus. The mastoid cells and the sulcus lateralis healthy. The lungs 
were free from tubercles. The thoracic and abdominal viscera healthy. 

Remarks. — This patient asserted that she never had any 



20 DISEASES OF THE NERVOUS SYSTEM. 

affection of tlie ear before she received the blow upon it. 
If this was so, the crust of new bone in the meatus must 
have formed in the five weeks preceding her death, and 
whilst the ulcerative process was advancing' in the tympa- 
num. The subject has a peculiar importance in a medico- 
legal point of view, since it might become, as perhaps it 
should have been in this case, a question before a jury 
whether the blow was the sole cause of death, or whether 
the deposit of bone was evidence of antecedent chronic 
disease. Our knowledge of the time within which exuda- 
tion ossifies does certainly not appear to contradict the 
statement of the patient. Admitting it to have been as she 
said, the immediate local treatment of such a case after the 
blow becomes in itself a subject of special interest. It did 
suggest itself at the bedside, if it were possible or not for 
this acute affection of the ear to have arisen from direct 
contact of the gonorrhoeal virus. 

The course of the disease in the tympanum in this case 
supplies another example of the uncertainty of any special 
diagnosis of the part of the encephalon which may suffer 
when the ear is affected. The caries and displacement of 
the stapes appear to have been followed by inflammation 
of a small vein of the vestibule, along which the inflamma- 
tion extended to the dura mater on the posterior part of the 
temporal bone, and thence to the cerebellum, whilst at the 
same time it set up caries of the wall of the meatus internus, 
and passed along the trunks of the auditory and facial 
nerves to the floor of the fourth ventricle. 

The occurrence of the facial palsy was in this case plainly 
owing to the extension of disease from the vestibule ; it is, 
however, worthy of note that this form of paralysis, in 
affections of the ear, does not necessarily imply so formid- 
able a complication. Not only may it occur from some 
temporary pressure of exudation in the bony canal, along 
which the nerve runs in its passage to the posterior part of 
the tympanum ; but in scalatina, as well as in some other 
cases, there may be attendant glandular enlargement, com- 
pressing the nerve after it emerges from the stylo-mastoid 
foramen. 

The chronic diseases of the ear which set up disease of 



ABSCESS OF THE BRAIN. 21 

tlie brain and its membranes, appear to be still regarded as 
too exclusively scrofulous in tlieir nature. The cheesy con- 
cretion wlaicli fills the tympanum in these cases, and which 
is assumed to be scrofulous matter, is generally only the 
debris of epithelium and pus, amongst which are scattered 
crystals of the ammoniaco-magnesian phosphate with plates 
of cholesterine and fine acicular crystals, probably of a fatty 
character. The presence of these latter crystals, which 
in form are not unlike urate of soda, may have given rise 
to the supposition put forth by some writers on the ear, 
that the affections of the tympanum are often gouty, but 
chemical analysis gives no indication of uric acid. For the 
most part, these chronic diseases begin as common inflamma- 
tion of the mucous membrane of the meatus, or tympanum ; 
or when they follow upon measles or scarlatina, they soon 
assume the ordinary conditions of common inflammation. 
When the bone suffers it is by ulceration, without under- 
going that change of structure which characterises scrofulous 
caries. A further proof of the non-scrofulous character of 
many of these cases is the absence of tubercles from the 
thoracic and abdominal viscera, even though the patients 
may have reached the adult period of life. 

From erroneous views of the pathology of this subject, too 
little attention is paid to local treatment, except in the hands 
of the aural surgeon. Accumulated exudation is permitted 
to keep up irritation and favour the extension of a disease, 
prejudged at first sight to be scrofulous, and to need only 
constitutional measures for its relief, when cleanliness, occa- 
sional local depletion, and the use of astringents would re- 
move it. 

Though local treatment must be often pre-eminent, it 
cannot be insisted upon exclusively ; for the subjects of 
such chronic inflammations are, for the most part, feeble 
and irritable, with fair hair and thin skin, and in whom 
nutrition often requires for its due performance the aid of 
medicines, as well as the most favorable hygienic conditions 
we can obtain. 

Mr. Toynbee's remarks on this subject are so important 
that I cannot but quote them.^ " There is no doubt,^' he 
1 Lectures, ' Medical Gazette,' 1855. 



22 DISEASES OF THE NERVOUS SYSTEM. 

says, '' that, as a general rule, an attack of inflammation of 
the ty panic mucous membrane arising in scarlatina, measles, 
or catarrh, subsides in persons having a healthy constitution, 
and it is usually in scrofulous constitutions only that the dis- 
ease becomes chronic. There are, however, many exceptions 
to this rule, and I think I shall make it evident that it is 
not the scrofulous diathesis of the patient which causes the 
disease to advance to the brain. As a general rule, to which 
I have found but few exceptions, the cause of the advance of 
the disease inwards to the brain appears to be that matter 
is secreted in one or more of the cavities of the ear, from 
which it has only a partial egress, or in which it is entirely 
pent up. Sometimes it is scrofulus matter (?), at others 
mucus or pus ; but whatever may be its mature or wherever 
it may be situate, I believe that its inability to escape 
externally is the cause of the progress inwards of the dis- 
ease.^' Of the importance of this last remark there can be 
no doubt ; but whether scrofulous concretion does occur 
under the circumstances alluded to, and if so, whether its 
removal would produce the same good effect as follows the 
removal of other accumulations, has yet, perhaps, to be 
proved. 

The same author has endeavoured to give greater pre- 
cision to this part of pathology, by showing that each of the 
cavities of the ear has its particular division of the ence- 
phalon to which it communicates disease. Thus, inflamma- 
tion of the external meatus will, with some special exceptions, 
extend to the lateral sinus and cerebellum ; inflammation 
of the tympanum to the cerebrum, and of the labyrinth to 
the medulla oblougata. Although the exactness and import- 
ance of the anatomical relations pointed out cannot be over- 
rated, and though, as Lebert, in his article on inflamma- 
tion of the lateral sinus, says the observations comes from 
too good a source not to deserve the highest consideration, 
yet we must demur accepting the pathological deductions 
until we have more clinical proof that disease in its extension 
from the ear does observe such direct and exclusive routes 
as the anatomical relations would imply. In the above case, 
the disease progressed from the tympanum, in all the three 
directions indicated, and death occurred from abscess of the 



ABSCESS OF THE BRAIN. 23 

cerebellum through phlebitis of the vein of the aqueductus 
vestibuli. In the ease of a young man, recorded by me/ the 
meatus externus and membrana tympana were healthy, yet 
the mastoid cells, as well as the roof of the tympanum were 
carious, and acute inflammation of the lateral sinus was the 
cause of death. In another patient, the bony meatus was 
carious, but disease had extended inwards and destroyed 
the roof of the tympanum and its posterior wall. Nor are in- 
stances wanting of acute disease of the meatus in the adult, 
setting up inflammation of the brain and its membranes, 
without implicating the mastoid cells or lateral sinus. When 
the course of the inflammation in any case is determined, 
the anatomical relations may enable us to anticipate what 
part of the encephalon may suffer ; as, for instance, if it be 
towards the mastoid cells, the lateral sinus and cerebellum 
will become affected ; if it be towards the roof of the tym- 
panum the cerebellum will suffer ; but they do not enable us 
to prognosticate from the beginning of a case what that 
course will be, whether exclusively in one direction, or gene- 
rally in all. As the routes by which disease of the ear may 
extend to the brain are three, so are there several modes of 
its extension. It may be by excessive implication of all the 
tissues, until at length the adjacent portion of brain is involved 
in the lesion, or it may be by extension along the veins only 
to the membranes, and thence to the adjacent portion of the 
brain ; or, lastly, abscess may occur in these cases as a secon- 
dary process, as it occurs where the primary malady is in 
some distant part. In this case, the abscesses may be multi- 
ple and isolated from disease in the ear by healthy tissue 
intervening. It is under these circumstances that the ori- 
ginal source of the malady is apt to be overlooked and the 
suppuration to be regarded as idiopathic. 

Case 4 (28). — Chronic disease of the mucous membrane of nose; acute 
abcesss in middle lobe of cerebrum. 
A gentleman, set. 43, strong, of good stature, and living at the time 
of his illness on his own estate in the country, went to church on Sunday 
morning, January 20th, 1855, in apparently good health. On his way home 
he suddenly felt a strange sensation of lightness in the head. He felt as 



^ ' Medico-Chir. Transact.,' vol. xxxviii, p. 158. 



24 DISEASES Of THE NEEVOUS SYSTEM. 

if lifted from the ground. As bis neighbours passed bim and spoke be 
could not comprebend wbat tbey said, and was unable to address them. He 
reached home safely, and soon recovered so as to be able to describe to bis 
wife wbat be had felt ; but shortly afterwards, when walking across the 
room, he staggered and fell down insensible and convulsed. The convulsion 
lasted a few minutes, and when be recovered be assured bis friends he felt 
quiet well and that it was only a faintness. During the afternoon, whilst 
lying on the sofa, the same sensation of lightness in the head returned again, 
and a second time he became insensible and was convulsed. Mr. Bottomley, 
of Croydon, now saw him, and prescribed suitable remedies. The following 
day the patient appeared quite well, and would take no more medicine. On 
Wednesday he went to town, and on bis return passed a restless night. On 
Thursday evening headache, of which he had had symptoms on Tuesday, 
returned with great violence. The pain was over the right temple, and in 
the occiput on the same side. I saw him first on the Friday afternoon, he 
was perfectly collected, complained of an agonising pain in the right temple 
and over the right eye. Exhibited great restlessness, now burying his bead 
in the pillow, and now pressing it with his hands for ease. He never in his 
life, he said, so much wished to be well, the pain was so dreadful. Pulse 80, 
with an occasional intermission. No throbbing of the carotids. Skin cool. 
Feet cold. Temperature of bead rather increased. Tongue moist and 
nearly clean. The bowels bad been relieved during the day. Urine of a 
pale sti'aw colour without deposits. Pupils small but active. No affec- 
tion of sensation or motion of any part. Slight nausea. No vomiting. 
The history I obtained from him and his family was as follows : — He had 
always had excellent health until four years before. He was then living in 
Australia, and at the time of sheep- shearing took cold in the left eye from 
a coup-d'air. He had then severe neuralgia of the left side of the head 
and face, lasting three or four days, and since that time returning at inter- 
vals. For three years be bad had symptoms of polypus nasi, and an attempt 
bad been made to remove one from the right nostril. There was a free 
watery mucous discharge which had not diminished with the accession of the 
cerebral symptoms. On the day previous to bis seizure be was out shooting. 
The weather was at the time extremely cold. After his death I learnt that 
at the end of the year 1853 he had a fall from his carriage, which stunned 
him for a shoii time. On the day after my visit he was seen by Dr. 
JeafEreson, who found his general symptoms unchanged, except that the pain 
in the head bad extended from the occiput to the upper part of the neck ; 
the pulse varied in frequency, and was sometimes at 50. No vomiting. 
No anaesthesia, nor affection of motion of any part. Occasional and slight 
incoherence. He died the following morning in coma. 

The post-mortem examination was made by Mr. Bottomley and Mr. Eden- 
borough, by whom I was kindly supplied with the following details, and 
witli portions of tlie diseased parts of the brain. 

In the posterior part of the middle lobe of the cerebrum, on the right side, 
wa.s a recent abscess of the size of a small orange. It had encroached upon 
the deeper layer of the grey matter of the convolutions over it, but had not 
reached the surface. The lateral ventricles contained a small amount of 



ABSCESS OF THE BRAIN. 25 

puriform fluid, but no communication was traced between them and the 
cavity of the abscess. On removing the brain from the base of the cranium, 
it was found to he much softened over the sella turcica, with recent inflam- 
matory exudation. The ethmoid bone was not observed to be carious. The 
interior of the nose was not examined, nor the viscera of the thorax or 
ahdomen. The pus was without fetor, greenish, and only slightly mucoid. 
There was no trace of a cyst. The tissue around was softened and vascular, 

Remarhs. — In tlie absence of any direct evidence obtained 
by examination of tlie interior of the nose after death, that 
disease existed there which might have occasioned the abscess 
in the brain, we can only infer the probability of its pre- 
sence from the clinical history and from the recent exuda- 
tion about the sella turcica. The absence of caries of the 
ethmoid would not be any valid proof against it, since it is 
established that the blood-vessels running through a bone 
may be the medium of extension of disease, and especially 
of acute disease, before the bone-tissue becomes carious. In 
the diseases of the ear there are many recorded examples in 
proof, and Case i6 (40), given below, though not one of 
abscess of the brain, is an illustration of this mode of exten- 
sion of disease from the nose to the contents of the cranium. 
When that case occurred my colleague. Dr. Wilks, spoke to 
me of a patient of his who had had a mucous discharge from 
the nares, and rather suddenly became the subject of acute 
meningitis. On a post-mortem examination the membranes 
on the under surface of the anterior lobes were adherent by 
recent lymph. There were no tubercles nor any other ob- 
vious exciting cause of the meningitis, and at the time the 
meningeal inflammation was attributed to cold, but from the 
history of Cases 4 (28) and 16 (40) it was probably only 
another instance of the course of morbid action indicated 
above. 

Case 5 (29). — Chronic thickening of lining of external meatus and tym- 
jyanum; ulceration of membrana tympani ; cavity of tympanum filled 
with soft cheesy concretion ; caries of petrous portion of temporal 
hone ; inflammation of right lateral sinus ; abscess on the surface 
of the posterior lobe of the cerebellum. 

George — , set. 13, one of the boys in the Licensed Victuallers' school, 
complained occasionally of pain in the right ear, from which there had been 
a purulent discharge, according to his mother's account, since he was a few 



26 DISEASES OF THE NERVOUS SYSTEM. 

months old. On the 29th May, 1S54, the pain in the ear was more severe 
than usual, and whilst standing in his class in the afternoon he suddenly 
became faint. During the night he was severely convulsed, and in one of 
the paroxysms pus is said to have been freely discharged through the nose 
with|immediate relief of the symptoms. June ist, he had no evident cere- 
bral disturbance. Pulse 96. Action of heart sharp but feeble, with irregu- 
lar rhythm. Pupils dilated. Sight unafEected. On the 2nd, he made great 
complaint of pain across the forehead and towards the vertex, and his manner 
was tremulous. Slight confusion on waking. Nausea, but no vomiting. 
Pulse 74, irregular. Respiration 24. On the 3rd, whilst out of bed, the 
convulsions returned. On the 5th, after a restless and delirious night, the 
pulse fell to 40, with a peculiarly sharp beat. Respiration 24, very irregu- 
lar in rhythm and extent, being sometimes thoracic and sometimes abdo- 
minal. Frequent alternations of flushing and pallor. Abdomen flattened. 
Evacuations dark and slimj-. With the complaint of pain in the forehead, 
he also made singular complaint of formication in the toes, and up to the 
hip in thejleft side. The following day the muscles of the leg became fre- 
quently cramped, and especially those of the great toe. From this date to 
the nth his symptoms underwent no important change. The pain in the 
head was severe, and principally referred to the forehead. On awaking 
from sleep his manner was frightened and confused. On the nth he com- 
plained very much of pain and formication in the left foot, over the instep 
and up the leg, it was felt slightly also in the arm. The pulse ranged from 
70 to So. The respiratory rhythm was often remarkably irregular, so as to 
defy any trustwortby statement of it for short intervals. The skin was hot 
and dry. Tongue slightly furred and protruded steadily. No vomiting. 
The ear continued to discharge freely. Towards the morning of the 12th 
he became rather suddenly comatose, and died in about half an hour without 
convulsion. 

Post-mortem examination. — The convolutions of the middle and poste- 
rior lobes of the right hemisphere of the brain were flattened, and there were 
traces of recent inflammatory exudation in the sulci under the arachnoid. 
On lifting up the posterior lobe from the tentorium an abscess was opened 
containing about an ounce and a half of pus. This abscess was irregularly 
bounded by the compressed convolutions, the falx major, the tentorium cere- 
belli, and the dura mater covering the petrous bone. It had not penetrated 
through the close arachnoid, but the subjacent brain-substance was softened, 
and of a faint gamboge tint. The lateral ventricles and central parts were 
healthy. No increase of ventricular effusion. The base of the brain and 
cerebellum without any traces of disease. The right lateral sinus thickened, 
the lower third obstructed by old coagulum, which apparently had formed 
slowly and was in part decolorised ; the upper two thirds contained recent 
fibrin and pus. The external surface of the dura mater in contact with the 
middle and inferior third of the sulcus was much injected, and the subjacent 
bone roughened, only a very thin shell remaining of the posterior wall of 
the tympanum. The superior surface of the petrous portion forming the 
roof of the tympanum was ulcerated into a hole as large as a goose-quill. 
The tympanic cavity was full of a soft, cheesy, yellowish concretion. The 



ABSCESS OF THE BRAIN. 27 

lining membrane thickened, and near the opening of the Eustachian tube it 
■was villous from delicate vascular folds. The posterior wall was excavated 
by ulceration. The contents of the cavity consisted of epithelium, granular 
matter, fat globules, and crystals of cholesterine. 

The Eustachian tube was healthy. The membrana tympani in great part 
destroyed by ulceration. The outer bones of the chain destroyed. The 
lining of the meatus much thickened. The viscera of the chest and abdo- 
men were all healthy. No traces of tubercle. 

BemarJcs. — The thickening and villosity of the membrana 
tympani appeared to be due to common inflammation. In 
its recent state, the membrane had much the appearance 
presented by chronic disease of the synovial membranes, 
when the formation of vascular fringes attends the ulcera- 
tive process. The bone had undergone a clean process of 
ulcerative absorption without any preceding infiltration of 
its structure. The occurrence of inflammation of the lateral 
sinus, with ulceration of the roof of the tympanum and 
abscess above the tentorium, seem to show that the prepon- 
derance of the morbid action in the one direction or the 
other, whether towards the cerebrum or the cerebellum is, as 
stated above, fortuitous. The disease probably began at the 
superior and inner portion of the meatus, extended through 
the membrane to the roof and posterior part of the tym- 
panum, and backwards to the superior part of the sulcus 
lateralis, the floor of which was carious for more than two 
thirds of an inch. 

In the report of the case it is stated that a discharge of 
pus through the nose gave relief to the symptoms for several 
days. At the bedside it was thought likely that there 
might be some communication with the suspected suppura- 
tion within the cranium, but this was proved not to have 
been the case as the dura mater was not perforated. It is, 
therefore, probable that the accumulation in the tympanum, 
which may have directly compressed the dura mater through 
the carious opening in the roof of the cavity, was thus re- 
lieved. 

Case 6 (30). — Chronic abscesses in liver probahhj set tip by an attach of 
dysentery ; recent abscess in left lung ; large undefined abscess in 
brain. 
Thomas D — , sst. 25, sailor, was in 1853 engaged in boat service in the 

Burmese war, when he fell ill with fever and ague, and was invalided for 



28 DISEASES OF THE NERVOUS SYSTEM. 

seven weeks. On his passage home to England, at the end of the year 1854, 
he was seized with pain in the left side, occasionally extending to the right. 
This was attended with cough, shortness of breath, and haemoptysis. He 
was admitted into Guy's Hospital, under the care of Dr. Hughes, February 
14th, 1855. His symptoms at that time were cough with expectoration of 
thin mucus ; pain on deep inspiration, and tenderness on pressure in the right 
hypochondrium, which was rounded and prominent ; morning sweats ; urine 
high coloured and depositing urates ; no icteric tinge of skin or conjunctiva. 
Dulness on percussion over right mammary and lateral regions of the chest, 
with absence of respiratory sound, tactile vibration remaining distinct. 
Chronic abscess of the liver was diagnosed. In the afternoon of the 21st, 
whilst conversing with one of his fellow-patients, he suddenly fell down 
convulsed. When seen shortly afterwards the eyes were open, pupils widely 
dilated and fixed, breathing stertorous, with puffing of the cheeks in expira- 
tion. The tongue had been bitten. The urine passed involuntarily. The 
skin was sodden with perspiration. Pulse 116. These symptoms continued 
for several hours, and induced some who saw him to think that an extensive 
efBusion of blood had taken place into the ventricles. In the evening five 
ounces of urine was drawn off by the catheter and found to be highly 
albuminous. The following day he was semi-comatose. Pupils dilated. 
Pulse 92. A pint of urine now drawn from the bladder was not coagulable 
by heat or nitric acid. Sp. gr. 1025, large deposits of urates on cooling. 
On the 23rd he had sufficiently recovered his consciousness to be aware of 
the pain of the blister which had been applied to the back of the neck. 
During the week following there was singular incoherence without delirium. 
His expression was vacant, and when he attempted to answer questions he 
frequently gave an unintelligible jargon or repeated words over and over 
again. There was no paralysis. On the 3rd of March he answered questions 
correctly but with hesitation ; said his memory was returned, and that he 
was no longer " so silly," though at times he had vertigo and mental con- 
fusion. On the 7th he had headache and vomited ; pulse 88. On the 9th 
the brain was again much oppre.ssed. He could tell his name but not his 
age ; this he tried to arrive at by enumerating the epoclis of his life — as, I 
was so old at such a time, and so old at another. On the 12th he vomited 
several times. On the 14th the same mental confusion continued ; instead 
of saying he has pain in his head, he says he has " pain in his pain." He 
does not recognise familiar objects though he sees them. When told to 
protrude his tongue he draws it back into the mouth. Hands tremulous. 
Pulse feeble. On the morning of the i6th he sat up in bed and drank some 
tea, but did not speak. An hour afterwards he was found lying on his Imck 
comatose. The right arm and leg paralysed. Both pupils dilated, the left 
the larger. Pulse feeble, 60. Respiration 28, entirely thoracic. Stertor 
with occasionally a deep sigh. During the two days following tliere was no 
important change in his symptoms. The pupils varied much witiiin short 
intervals, probably from changes in the circulation, as shown by the alter- 
nate flusliing and pallor of the face. Optic axes divergent ; eyelids not 
closed. Conjunctiva on right side congested. The only traces of conscious- 
ness were in the movements of the left arm, which he often put to his head 



ABSCESS OF THE BRAIN. 29 

or used to replace the bed-clothes when disturbed. Died March 19th, 
twenty-six days from the onset of the cerebral symptoms. 

Post-mortem examination. — Cranial bones, dura mater, and sinuses 
healthy. On removing the calvaria, an abscess was at once obvious at the 
surface of the posterior lobe of the left hemisphere, breaking through the 
cineritious substance. The cavity of the abscess was undefined. It con- 
tained about an ounce and a half of greenish mucoid pus, not fetid. The 
surrounding cerebral substance, including the whole of the middle lobe of 
the cerebrum, was softened and yellowish, from infiltration of inflammatoiy 
products. There had been haemorrhage from the anterior and outer wall of 
the abscess, forming a coagulum as large as a walnut, which was partially 
mixed with the pus. The left lateral ventricle was full of pus, which had 
escaped from the abscess through a rent in the posterior cornu. The right 
was distended with about an ounce of clear fluid. At the base of the brain 
there were tender filaments of recent lymph between the two surfaces of the 
arachnoid. The left crus cerebri was slightly softened. Old and recent 
adhesions at the bases of both lungs. 

An abscess of the size of an egg, filled with mucoid pus, in lower lobe of 
left lung ; tissue around consolidated. Base of right lung in an early stage 
of pneiimonia. Mucous membrane of colon thickened and slate coloured. 
In many parts well marked cicatrices of old ulcers. The calibre of the gut 
unequal. No existing ulceration. In right lobe of liver two chronic 
encysted abscesses, each as large as a duck's egg, one on the upper surface, 
the other in contact with the kidney. The cysts were remarkably thick and 
tough ; they contained greenish mucoid pus, not fetid. The cyst of the 
deeper-seated abscess was at one part softened, and there was recent inflam- 
mation in the secreting texture adjacent. 

Eemarhs. — In this case^ one of the chronic abscesses in 
the liver appears to have become, by recent inflammation of 
its sac and of the adjacent structures, the source of secon- 
dary abscess in the lung and brain. From the nearness of 
the abscess to the surface, it may be inferred that the sudden 
and severe convulsion which was the opening symptom of 
the cerebral affection, was connected with membranous irri- 
tation, traces of which existed as tender filaments of adhe- 
sion between the two surfaces of the arachnoid. 

The sudden seizure on the fourth day before his death 
may have been connected with the unusual accident of 
haemorrhage into the abscess, rather than with the rupture 
of it into the lateral ventricle. The progress of the abscess 
inwards towards the posterior cornu appears to have caused 
ventricular effusion, which filled the right ventricle, whilst 
the left was full of the pus which had recently been poured 
into it from the abscess. 



30 DISEASES OF THE NERVOUS SYSTEM. 

Case 7 (31). — Encysted abscess in middle lobe of right heynisjyhere ; wn- 
defined abscess in anterior lobe of left. 

J. S — , set. 43, farm labourer; light hair; florid complexion; muscular. 
Had symptoms attributed to inflammation of the liver, from which he con- 
valesced. On the first day of his return to worlv, the weather being hot, 
with a bright sun, September 13th, 1844, he was seized with severe pain 
over the left eye at the supra-orbital notch. He passed a restless night, and 
the following day the pain was unabated. He said he could cover the 
painful part with his thumb. Pulse 72. Tongue clean. Skin cool. Bowels 
open. The case was treated, as one of neuralgia, with quinine. On the 
third day there was no improvement ; he was drowsy, and the articulation 
defective. He was now purged, leeches were applied to the forehead, and a 
blister behind the ear. Calomel and antimony given every four hours. On 
the seventh day he was drowsy, but could be roused, and answered questions 
rationally. Articulation more confused — for " sleep " he said " spleep." 
Occasional incoherence. Sight of left eye dim. He was bled to twenty 
ounces. This was followed by profuse perspiration, and the pulse rose to 72. 
On the eighth day he was semi-comatose. Cupped to six ounces. Inunction 
of mercurial ointment. On the tenth day comatose. Several severe tremors 
(convulsions ?) during the night. Pulse small and frequent. Constipation 
for three days. Arteriotomy to six ounces. Leeches to the head. A minim 
of croton oil every two hours, and ten grains of calomel with each dose. 
Died on the eleventh day. 

Post-mortem examination. — The body that of a fine stout man. Abdo- 
minal viscera healthy, with the exception of traces of recent inflammation of 
liver. Left lung universally adherent, right lung only partially so. Dura 
mater firmly adherent to the calvaria. An abscess without definite walls, 
containing about three drachms of pus, in the posterior and outer parts of 
the left cerebral hemisphere, near the surface. The surrounding cerebral 
substance soft and pulpy. In the middle lobe of the right side an encysted 
abscess, with firm, membranous vascular walls. This had bui-st through 
the softened optic thalamus into the lateral ventricle. 

Remar'ks. — For this case I am indebted to my friend, Mr. 
Brickwell, of Sawbridgewortli. The early symptoms of 
hepatitis may have had their origin in cerebral irritation 
from the presence of the encysted abscess. This must have 
been for some time latent. Traces of capsulation have not 
been found earlier than the third week. A cyst as firm and 
vascular as that here described would have required five or 
six weeks at least for its formation. It may have been latent 
much longer than this period. It is notoriousl}- diflficult 
in many cases to determine whether certain symptoms have 
a cerebral or a gastric origin. Biliousness is often a promi- 



ABSCESS OF THE BRAIX. 31 

nent feature in the account patients give of the early indis- 
position in any cerebral affection. 

The intense neuralgic pain over the left eye, which 
ushered in the fatal attack, and which was probably a 
symptom of the acute abscess in the left hemisphere, was 
noticed also in Case 4 (28), and, at the outset, led to a similar 
error in diagnosis. The pain was so intense and so limited, 
and had followed in that case so immediately after exposure 
to intense cold in field-sports, that its neuralgic character was 
quite deceptive. 

The occurrence of an acute abscess in conjunction with 
one encysted, is in this case ambiguous. They may have 
arisen from some common source not discovered at the post- 
mortem examination, as in the ear or nose. Or the former 
may have arisen as a secondary (phlebitic ?) result of the 
latter. This origin seems more probable, since recent 
changes had taken place in the cyst leading to its rupture, 
and to softening of the adjacent thalamus. 

Case 8 (32). — Abscess in sheath of left rectus abdominis muscle ; ahscesses 
in brain and cerebellum, 

Richard F — , set. 46, labourer, applied at the hospital as an out-patient 
under my care 13th of November, 1854. Complained of being generally 
unwell and weak, and of a swelling near the superior attachment of the left 
rectus abdominis muscle, which on examination was found to depend upon a 
chronic abscess in the sheath. He had been unwell for a fortnight, but 
had observed the swelling only three days. He could give no account of 
any exciting cause. The pulse was 100. Tongue furred. Herpes about 
lips. Urine high coloured and albuminous. He was admitted into the 
hospital under the care of Dr. Addison, and the abscess was opened the same 
day. No symptoms occurred to arrest particular attention until the 17th, 
when the face was observed to be paralysed on the right side, and the same 
day he had a well-marked rigor. He appeared to be much debilitated, and 
had mild typhoid symptoms. On the i8th deglutition was difficult, and his 
speech indistinct. There was no decided paralysis of the extremities, but he 
was remarkably powerless, the left side being apparently weaker than the 
right. He lay from day to day in a semi-comatose condition, from which 
he could be partially roused. Urine and faeces passed involuntarily. Almost 
total inability to swallow. Skin hot. Pulse 96. Towards the end the 
breathing was stertorous, with loud moaning. He died November 23rd, six 
days after the onset of the cerebral symptoms. 

Post-mortem examination. — No wound or scar on the body, except 
that into the sac of the abscess in the sheath of the left rectus muscle. 



32 DISEASES OF THE NERV^OUS SYSTEM. 

The integuments of the head and the calvaria healthy. The convolntions of 
the right hemisphere flattened. The surface of the arachnoid greasy. 
Exudation of plastic matter in the course of the large veins, between the 
convolutions. In the anterior part of the right hemisphere, near the surface, 
was an abscess containing about three drachms of greenish fetid mucoid pus, 
and on the same side, more deeply seated in the white substance, and more 
posteriorly, were four other smaller abscesses containing pus of the same 
character. They were all defined by a slight circle of injected vessels, 
outside of which the nervous tissue was normal. The contents, examined by 
the microscope, showed but few well-formed pus-cells, the larger amount 
consisting of granular matter. The lateral ventricles were healthy, as were 
also the corpora striata, thalami, crura cerebri, and pons Varolii. In the left 
lobe of the cerebellum was a fifth abscess, situate so near the under surface 
that its contents were discharged by removing this part of the brain from 
the cranium. The sinuses of the dura mater and the bones of the base 
healthy. Thoracic viscera healthy. Liver rather pale. On its superior 
surface, near the anterior border, the tissue was softened at two spots from 
recent inflammation. The splenic tissue was mottled. In neither of these 
viscera was there any purulent formation. Kidneys healthy. Bladder 
thickened. A circular stricture of the urethra about an inch from the 
meatus. 

Remarlcs. — According to the prevalent theorj^ of tlie secon- 
dary deposits in pyaemia, the lungs ought to have suffered 
before the brain in this case, provided, as was most probable, 
that the exciting cause of the secondary suppuration was 
the abscess in the sheath of the rectus abdominis. Case 9 
suggests the same criticism, and, as before remarked, even 
more obviously than this one, since there the infected blood 
had to traverse both liver and lungs before it reached the 
brain, and produced its morbid effects. It is a characteristic 
example of the insidiousness of pya^mic suppuration in the 
brain. Slight facial paralysis was the first symptom. But 
for this and the occurrence of a rigor, there was little to 
distinguish the case from one of ventricular and sub- 
arachnoid effusion in a subject debilitated by chronic 
disease. 

Case 9 (33). — Peyers jyatclies in loxcer portion of ileum, prominent and 
slate-coloured ; chronic suppuration of the mesenteric glands ; many 
abscesses in brain ; abscess in right kidney and spleen. 

A gentleman, set. 45, above the middle height, originally of rather a 
delicate constitution, which had been weakened by a too laborious and 
anxious city life, as well as by neglect of regular meals and absence from the 



ABSCESS OF THE BRAIN. 33 

use of all fermented liquors, was at the end of February, 1857, taken with 
febrile symptoms, accompanied with a rigor which returned about every 
twenty -four hours. The homoeopathic practitioner i;nder whose care he was 
supposed it to be a case of ague. In a few days the rigors became more 
severe, and were followed by intense neuralgic pain in the right side of the 
head and face. After one of these attacks, about ten days from the com- 
mencement of his symptoms, he was suddenly stricken, whilst shaking hands 
with a friend, with paralysis of the left side, including the face. There was 
no unconsciousness, and though the speech was affected he was still able to 
express himself so as to be undei-stood. The rigors continued to return at 
irregular intervals of one, two, or three days. After each the sweating was 
profuse. On two occasions there was hiccough lasting for many hours. 
He was often drowsy, but never had headache, nor delirium, nor incoherence. 
At my visit, a few hours before his death, I found him perfectly collected, 
and on my asking him if he had pain in the head, he replied in the negative. 
His expression was tranquil. Pupils natural. The left arm and leg quite 
paralysed ; the muscles flaccid and wasted. Tongue proti'uded to the left, 
its surface dry and brown. Abdomen flat. Urine and faeces had passed 
involuntarily for ten days. Pulse 130, feeble. On inquiiy as to any cause 
which could have given rise to suppuration in the brain, which from the 
symptoms was suspected, nothing but negative evidence could be elicited. 
From boyhood he had often complained of a painful tightness over the fore- 
head, and when fifteen yeai-s old had rather a severe fall. He died on the 
17th of March, soon after my visit, fifteen days from the paralytic seizure 
and three weeks from the onset of the fever and rigors. 

Post-mortem examination. — Body emaciated ; muscles of left side espe- 
cially wasted, and without the rigor mortis which existed on the opposite 
side. Under the arachnoid of the upper surface of the hemispheres several 
spots of ecchymosis, one as large as a florin. The middle third of the right 
hemisphere down to the coi-pus striatum was softened, leaving no distinction 
in the affected convolutions between the cortical and medullary structures, 
the whole being of a yellowish-grey colour and of the consistence of cream. 
Amongst the softened portion there were recent dark coagula, and a defined 
but not encysted abscess as large as a filbert. Throughout the medullary 
substance of both hemispheres there were numerous spots of suppuration 
from the size of a hempseed to a pea, defined but not encysted, looking like 
drops of pus deposited in healthy nerve-tissue. One of these abscesses, as 
large as a horse-bean, was seated in the inner grey nucleus of the right 
corpus striatum. The other parts of the brain and cerebellum were healthy. 
In the diploe of the pari of the calvaria removed, there were some spots of 
venous congestion visible through the inner table. In the centre of one 
larger than the rest the bone was softened, and there was pus in the cancelli. 
The ethmoid and temporal bones and tympana healthy. Hypostatic engorge- 
ment of lungs ; heart flabby ; liver healthy. Two collections of pus, each 
the size of a hazel nut, in the spleen, and one in the cortical portion of right 
kidney. The mesenteric glands con-esponding to the lower portion of the 
ileum were enlarged and slate-coloured, and several in a state of suppuration^ 
apparently chronic. Peyer's patches prominent, and mottled by slate- 

3 



34 DISEASES OP THE NERVOUS SYSTEM. 

coloured dots ; no ulceration. The coats of the small intestine at other 
parts were remarkably thin. 

Remarks. — The prominence and colour of Payer's patches 
in the lower part of the ileum ^Yere indications of some prior 
attack of ileitis. Of the occurrence of this, no other evi- 
dence could be obtained. The enlarged and suppurating 
glands of the mesentery corresponded to that part of the 
ileum so affected. The patient was a feeble person, in 
whom it might have been expected that local disease would 
extend. It is remarkable that with such extensive diffusion 
of the suppurative action in the brain there was never any 
headache nor delirium. The occurrence of the paralysis, as 
in many other forms of softening, was quite sudden. The 
rigors may have been referable to the suppuration under the 
capsule of the spleen and in the kidney, as well as to that 
in the brain. 

Case io (34). — Phlegmonous erysipelas of upper lip extending to the orhit ; 
suppuration behind the globe ; ulceration of the dura mater ; defined 
abscess in anterior lobe of cerebrum. 
W. R — , jet. 16, a delicate boy employed in the stables at the South 
Eastern Railway, came under treatment at the beginning of May for phleg- 
monous erysipelas of the upper lip and right side of the face, which he ascribed 
to inoculation from an unsound horse. The inflammation extended to the 
forehead and eyelids. Abscess formed in the right orbit, and the globe pro- 
truded. There was pain in the left side of the head, radiating from a little 
behind the anterior fontanelle. A quantity of thick, creamy pus was 
evacuated from the orbit by puncture, and the pain over the left temple was 
for a time completely relieved. The eye gradually returned to its place, the 
chemosis abated, and almost all inflammatoiy appearances in it slowly sub- 
subsided. He did not, however, recover his sight, though he gradually 
began to perceive a yellow-coloured light. The pain over the left side of the 
head returned a second time, and extended down behind the left ear and 
along the lower jaw. It was somewhat intermittent. No disturbance of 
the intellect. No paralysis, nor any symptom, except the pain, to indicate 
disease of the brain. He improved in flesh and strength. The headache 
lessened, and at times almost left him. At the end of three weeks he 
seemed to have regained his usual health. Whilst walking in his garden in 
the afternoon, about five o'clock, he complained of a dull, heavy feeling in 
the head, with vertigo. This went off after he had rested a little, and 
excited no alarm. 

At 8 p.m. the same evening he suddenly fell into general convulsions, 
which lasted half an hour, leaving him comatose. The convulsions returned 



ABSCESS OF THE BRAIN. 35 

after a short interval, and he died an hour and a half after the commence- 
ment of the first fit. 

Post-mortem examination. — On lifting up the brain from the base of 
the cranium, the membranes were found matted together on the right side 
over the inferior surface, near the fissure of Sylvius. The dura mater, where 
it covered the back of the orbit, was perforated by an opening communicating 
in one direction with the pus in the orbit ; and in the other leading into an 
abscess in the middle lobe of the brain. Nearly two thirds of the middle 
lobe were involved in the inflammatory process. The pus was not circum- 
scribed by a cyst, but surrounded by softened brain, outside of which there 
was induration, and beyond this, again, softening and hypertemia. 

Except slight flattening of the convolutions, and general fulness of the 
vessels (probably due to death by coma), no other morbid appearances were 
noted. 

Remarks. — The above case was kindly sent me by my 
friend, Mr. Frederick Moon, under whose care it occurred. 
One of the points of interest in it was the seat of the pain 
in the head, which the patient always complained of on the 
left side, although the suppuration was in the right hemis- 
phere. A somewhat similar case, as regards the origin of 
the suppuration, was under the care of Mr. Birkett, in May, 
1854. A man, aet. 46, was admitted for slowly extending 
(malignant) ulceration, involving the whole side of the face 
and orbit. His principal symptom was headache. An en- 
cysted abscess of the size of a hen^s egg, and containing 
fetid pus, formed in the middle lobe of the cerebrum, and 
extended inwards to the lateral ventricle, which contained 
pus. The dura mater was involved in the external ulceration, 
and the membranes were generally inflamed with consider- 
able sero-purulent effusion over both hemispheres. 

In this case the abscess was evidently of some date, and 
had formed apparently as an isolated and secondary result of 
the ulceration on the face, as it might have done had the 
primary disease been in a more distant part. 

Case i i (35). — Fall hackwards from a cart ; immediate effects overlooTced ; 
after a fortnight symptoms of continued fever ; partial recovery ; 
sudden insensibility and convulsions ; hemiplegia of right side; 
death ten weeks after fall ; abscess in left hemisphere, and in sphe- 
noidal sinus. 

Francis L — , set. 16, a delicate boy, was admitted into Guy's Hospital, 
December 23rd, 1844, with symptoms supposed to be due to an attack of 
typhus in a mild form. For the first fourteen days the case did not attract 



36 DISEASES OF THE NERVOUS SYSTEM. 

particular attention, and appeared to be progressing favorably. January 7th, 
he complained of pain in the head, which was relieved by leeching and 
blistering. On the i8th he was considered convalescent, and walked about 
the ward. He went on well until the 24th, when he was found in bed 
insensible. The eyes were open and fixed ; mouth drawn to left side ; con- 
vulsive tremor of hands and legs, followed by a succession of epileptiform 
convulsions, lasting for three hours, after which he lay for some time as in 
a profound sleep. On inquiry of his friends it was found that three weeks 
previous to his admission into the hospital he had slipped and fallen back- 
wards from a cart, striking his head on the ground and being stunned for a 
minute or two. There was neither wound nor bruise perceptible. For a 
foi-tnight following the accident he complained of nearly constant pain in 
the back of the head, and was generally indisposed, but not so unwell as to 
prevent his following his employment. At the end of the fortnight the pain 
in the head was more severe, and he had chilliness, languor, and loss of 
appetite, and was sent to the hospital as a case of fever. On the day 
following the convulsions (January 25th) he was partially sensible, seemed 
to comprehend what was said to him, but made no attempt to speak. He 
had a puzzled, confused expression, but protruded the tongue when told to 
do so. Pupil contracted, but obedient to light. Urine and freces passed 
involuntarily. During the next two days he became more sensible, and on 
the 28th spoke, and complained in a general way of pain in the head. On 
the 30th he vomited, and from 9 a.m. to 2 p.m. had a series of epileptiform 
convulsions, after which he lay in a state of coma. On the 31st he sat up 
in bed and put out the tongue when told, but did not appear to recognise 
his friends, nor could he be made to speak. The right arm and leg were 
completely paralysed. The tongue was pointed to the right ; face occasion- 
ally drawn to the left. When the left arm was lifted up it remained for 
some time unsupported in that position, as in catalepsy. Breathing natural. 
Pulse feeble and quick. Gums afBected by mercury. Towards morning, 
February ist, he was for a short time violent and excited in manner. 
During the day it was noticed that the face was less paralysed, and that he 
could to some extent move his right arm. He answered questions in mono- 
syllables, and talked incoherently to himself. When the tongue was pro- 
truded he seemed to forget to draw it into the mouth again. His expression 
was remarkably vacant. He sat up in bed by himself, and was incessantly 
catching at imaginary objects about his dress. A careful scrutiny was made 
of the head with the view of trephining, but no trace of any wound or bruise 
could be detected. All medicines were omitted, and the ferrum candens 
applied to the vertex. For the next few days there was no important 
change. He occasionally vomited, without any apparent cause, and started 
up in bed agitated. The pulse was about 60. He had a stupid, oppressed 
look, but was not insensible, and could articulate slowly, with tolerable 
distinctness. From the 8th he became semi-comatose, and could be only 
partially roused. No stertor. Pulse 60. The food placed in his mouth 
remained unmasticated. A succession of convulsions came on during the 
night of the loth, and he died early the next morning, about ten weeks 
from the accident. 



ABSCESS OF THE BRAIN. 37 

Post-mortem examination. — No marks of injury were perceptible either 
upon or within the cranium. The cerebral convolutions were flattened. 
The arachnoid membrane dry. Tlie vessels congested. The lateral ventricles 
contained an excess of fluid. In the left hemisphere, a little below the level 
of the corpus callosum, was an encysted abscess, containing between two and 
three ounces of serous fluid, in which there was a sediment of greenish-yellow, 
thick pus, whilst flocculi of lymph floated above it. The wall of the abscess 
was formed bj a well-organised false membrane, having internally a smooth 
mucous surface. The abscess encroached on the corpus striatum and thalamus 
opticus. The cerebellum and other parts of the brain healthy. The pro- 
cessus olivaris of the sphenoid bone was carious, and around it there was a 
deposit of new bone. Under this part of the cranium, in the sphenoidal 
sinuses, was a symmetrical abscess, encysted like that in the brain. It had 
no communication with the cavity of the cranium. Heart healthy. Pneu- 
monic consolidation of the posterior parts of both lungs. Calcareous deposit 
in the bronchial glands. Intestines glued together by old adhesions. Other 
viscera healthy. 

Remarks. — Injuries to the head, as in this case, are a 
fertile source of, so-called, idiopathic cerebral abscess. The 
subject presents difficulties which cannot be altogether sur- 
mounted. In the routine of life there will always be, on 
the one hand, a foi'getfulness of such events as these, if they 
do not lead to immediate results, and, on the other, an acute 
remembrance of trifles, however absurd, which happen to 
be associated with the beginning of any symptom. These 
failings of human nature will perplex us at the bedside in 
proportion to our want of clinical experience in the particu- 
lar cases under consideration. This alone can tell us the 
value of negative evidence. The peculiar course of cases 
like the above has been already remarked upon, and the 
chief points of difference from continued fever enumerated. 

Case 12 (s^). — Cirrhosis of left lung from pleuro -pneumonia in child- 
hood ; dilated bronchial tubes ; encysted abscesses of brain. 

Jane T — , set. 17, a thin, delicate girl, dark hair, rather sallow complexion, 
never had menstruated, was, on several occasions from the age of fourteen, 
an out-patient of Guy's Hospital, under my care, for cough and punilent 
expectoration, with occasional haemoptysis. When three years old had 
measles, with pleuro-pneumonia of the left lung ; this was followed by 
hooping-cough. Flattening and general contraction of the left chest resulted, 
with the ordinary signs of obliterated pulmonary tissue and dilated bronchial 
tubes. On the 27th of January, 1855. she sickened with variola, which 
assumed a semi-confluent form. In the stage of maturation the habitual 



38 DISEASES OF THE NERVOUS SYSTEM. 

cough became more severe, and the expectoration was increased. On the 
14th of February she appeared to be convalescing favorably, except that her 
manner was rather dull and she complained of headache. During the 15th 
and 1 6th there was no noticeable change. On the 17th she became delirious 
and left her bed, thinking her room was on fire ; her mother found her 
sitting on the stairs, cold and faint. After being put to bed she had a well- 
marked rigor, and complained of increased headache. On the i8th the left 
arm was observed to be paralysed ; she could move the leg on the same side 
readily, and the face was unaffected. There had been no convulsion. Her 
manner was dull, but when urged to speak she could answer intelligibly. 
Pulse 84. Constipation. During the 20th and 21st she complained of great 
pain in the left leg, and early on the 22nd began to move it incessantly up 
and down in bed, the left arm remaining motionless. The constipation per- 
sisted, notwithstanding the repeated administration of purgatives, during 
three days. About noon she rather suddenly became comatose, and died the 
same day. 

Post-mortem examination. — On removing the calvaria and dura mater, 
the convolutions on the right side were seen to be flattened as by pressure 
from within. The minute vessels of the pia mater on both sides were con- 
gested. The right lateral ventricle contained three drachms of greenish 
mucoid pus, without smell, which had escaped from an encysted abscess 
occupying the whole of the right optic thalamus, and pressing upon the 
adjacent coi-pus striatum. The body of the fornix and septum lucidum were 
softened and broken down. In the posterior third of the left hemisphere 
were two smaller encysted abscesses, containing each about a drachm and a 
half of pus. The wall of the cyst of the larger abscess was from a line to 
a line and a half thick. It consisted of fibro-cellular tissue. The inner 
surface smooth, like mucous membrane, highly vascular, of small, irregularly 
dilated, meandering veins. The brain-substance around was softened, appa- 
rently from oedema only, no exudation-cells being discovered amongst the 
loosened nerve-tubules. The bones of the head and the sinuses of the dura 
mater were healthy. The left lung was universally adherent, and only with 
much difficulty removed from the chest ; it weighed fourteen and a half 
ounces, and sank in water. On section there were irregular cavities through- 
out it, communicating with the bronchi (dilated tubes) ; these were lined by 
a delicate membrane of a dark venous colour, continuous with the vascular 
lining of the bronchi. Three of them were of considerable size, one near the 
apex being as large as a hen's eg^. The pulmonary tissue was entirely 
destroyed, and replaced by a dense fibrous structure, incoi-porated with the 
thickened pleura. The right lung was healthy, as were also the abdominal 
viscera. No trace of tubercle. 

Remarks. — The latency of the abscesses in this case, and 
their relation to the chronic disease in the chest, have been 
referred to above. The occurrence of smallpox may have 
been a determining cause of augmented activity in the cysts, 
and may thus have promoted the fatal termination ; but there 



ABSCESS OF THE BRAIN. 39 

is no probability, as before stated, that tlie smallpox had part 
in exciting the suppuration, since this must have been long 
antecedent to the operation of the variolous poison. This 
and the two following cases are instances of a similar asso- 
ciation of chronic disease of the chest with cerebral abscess. 

The doctrine of final causes, so freely quoted by modern 
pathologists in explanation of morbid phenomena, receives a 
shock from the facts of cerebral abscess. Whatever '' elforts 
of nature " the course of abscess elsewhere may seem to 
show, we can recognise in its course in the brain but 
mechanical principles, according to which the yielding is in 
the direction of least resistance, and the pus thereby slowly 
makes its way towards the cavity of the lateral ventricles 
irrespective of the well-being of the individual. 

The sudden accession of delirium was probably brought 
on in this case by such an accident. In a similar case, 
recorded by Abercrombie, a man, set. 43, had for ten days 
complained of headache, but was still able to follow his 
employment. Early one morning he was seized with palsy 
of the left side of the face, and became unmanageable. The 
pupils were contracted and the eyes in perpetual motion. 
He made the most powerful resistance against being bled. 
He died on the fourth day. Three encysted abscesses were 
found in the brain, the largest of which had burst into the 
lateral ventricle. 

Case 13 (37). — Pleuro-pneiimonia of the base of right lung, followed by 
fetid expectoration ; death after three years from encysted abscess in the 
brain; cavity in lower lobe of right lung, with several bronchial tubes 
opening into it. 

A gentleman, tet. 34, tall and well proportioned, with light hair and fair 
complexion, was in good health until December, 1853, when, from exposure 
to cold, he had an attack of acute pleuro-pneumonia of the lower lobe of the 
right lung. In March following the symptoms returned, and he began to 
expectorate muco-piuulent fluid of a peculiar earthy fetid odour. In a few 
weeks he was able to go to business, but was never again robust. The expec- 
toration continued purulent and fetid. Exacerbations of the local chest- 
symptoms occurred from time to time, and were generally attended with 
slight hsemoptysis. 

In this way he went on until March, 1856, when he had a sudden seizure, 
lasting for nearly two hours. The symptoms were vertigo, faintness, and 
loss of power on the right side ; he was not unconscious. The day following 



40 DISEASES OF THE NERVOUS SYSTEM. 

he was at his business as iisual, but ever after he would at times complain of 
a tired feeling in the head, and was easily fatigued. Singing at church and 
other loud noises distressed him. With these exceptions, however, he 
appeared in his usual health, and continued to perform active duties ; and 
though I often saw him for the chest affection, he never complained of 
anything in the head. November 15th, about two o'clock, he was surprised 
by a sudden and violent chronic convulsion of the right arm, lasting for 
several minutes. It was so severe as to oblige him to support himself by 
holding the table with the other hand. He felt quite well at the time, and 
when the muscular action subsided went on with his duties as before. He 
left the warehouse at four o'clock, and was walking to the omnibus, when 
the right arm was similarly affected a second time for a minute or two. He 
still felt quite well, and took his place in the omnibus, but had not proceeded 
far before the movements returned a third time, now affecting slightly the 
muscles of the face and of the leg on the same side. After lasting as before, 
but a few minutes, they again left him. When I saw him at six o'clock he 
appeared quite well. The voluntary movements were everywhere perfect ; 
vision and pupils natural ; no headache nor trace of mental disturbance, and, 
with the exception of slight and transient vertigo at the time of the third 
return of the movements, there had been no symptom referable to the brain. 
He assured me he felt quite himself, and on my requesting him to walk 
round the room and examine the pictures and engravings on the walls, he 
asserted that he saw them quite naturally. He continued well until noon of 
the following day (November i6th), when the convulsions returned a fourth 
time, beginning in the same way with clonic spasms of the arm and face, on 
the light side, without loss of consciousness, but quickly assuming the 
character of a severe epileptic seizure, with insensibility. After two hours 
he recovered, and the next day (the 17th) wrote to his sister, and complained 
only of weakness. On the i8th he had another convulsion, with insensibility, 
followed by partial paralysis of the right arm and leg. On the 20th he 
slept nearly the whole day ; when awake he was quite himself, except the 
inability to move the right arm and leg freely. Up to this time he had no 
headache, and no delirium. On the 21st and 22nd he continued in the same 
state ; pulse 80 ; skin cool ; no heat of head ; perfect clearness of intellect 
when fully awake ; slight headache towards evening ; constipation. On the 
24th the arm and leg were more numb and powerless ; about noon the whole 
side was convulsed, and he became insensible. The convulsions continued, 
with only short intervals of quiet, until 4 p.m. After consciousness returned 
he remained speechless for many hours. On the 25th and 26th he was 
much troubled by the almost constant recurrence of the clonic convulsion of 
the right side, including the face, but without insensibility. After the 
application of leeches, a blister, and free evacuation from the bowels, he was 
much relieved, and slept tranquilly. On the 27th he complained of a "dead 
pain " in the head ; there was still no febrile heat ; he raised the right arm 
with more power ; pulse 80. On the 29th the arm and leg were quite paralysed ; 
the muscles flaccid ; sensation not much diminished. By this time he had 
greatly emaciated ; when asked if he had pain in the head, he replied slowly 
— " 1 ought hardly to say pain," and aftei-wards added, with a smile, that he 



ABSCESS OF THE BRAIN. 41 

was comfortable. The administration of an enema brought on convulsion 
without insensibility. On December 3i-d there was great cerebral depression ; 
he used words incoherently, asking for one thing when he meant another. 
There had been no convulsive movements for two days, but now and then he 
seemed to faint for a time ; the left hand was constantly pressed to the left 
side of the head ; the right arm and leg were perfectly paralysed, and the 
muscles of the face on the same side partially so ; pulse 80 ; tongue pro- 
truded straight. On the 4th he uttered a few sentences very slowly and 
interruptedly, but lay for the most part in a half comatose state ; took food 
readily. During the 4th, 5th, and 6th, he lay perfectly quiet, occasionally 
breathing with a little stertor, but generally so calmly that it was difiBcult to 
say whether he bi-eathed or not ; could be roused, and understood what was 
said to him ; expressed by signs his desire to have food and the like. On 
the 7th the urine passed from him involuntarily, though he retained his 
consciousness, and once smiled faintly when his sister was near him. 
From his movements it was evident he suffered a good deal of pain in 
the head. He could not understand questions, but recognised signs ; pulse 
56; respiration 20 ; pujails equal, rather less contracted than in sleep ; abdo- 
men collapsed ; several rigors, followed by spasmodic extension of the whole 
body. On the 8th was unable to swallow ; towards evening very severe con- 
vulsions came on, and lasted several hours, when he died exhausted. 

Post-mortem examination. — The integuments of the head and calvaria 
healthy. In the posterior lobe of the left hemisphere of the brain, on a level 
with the corpus callosum, there was an encysted abscess, containing two 
ounces of mucoid, greenish, fetid pus. The cyst was bounded externally by 
a thin layer of greenish brain-substance, the membranes over it were not 
inflamed. The wall of the cyst was about one tenth of an inch thick ; it was 
vascular. The brain-tissue around was softened from inflammatory cedema. 
Slight increase of fluid in the lateral ventricles. Xo disease of the temporal 
or of the other bones at the base of the cranium. Finn pleuritic adhesions 
over the lower lobe of the right lung, and an irregular cavity, as large as a 
pullet's egg, in the pulmonary tissue. The lining membrane of this cavity 
was smooth and transparent, and on the proximal side perforated by several 
bronchial tubes. The tissue around was indurated. No trace of tubercle in 
any of the tissues. Abdominal viscera healthy. 

Bemarlis. — The sudden seizure in March, though so 
transient that it caused no alarm, was probably indicative of 
the commencement of the suppurative process in the brain, 
which afterward pursued, during eight months, an entirely 
latent course. 

The order of the symptoms in the final attack, was charac- 
teristic of the onset and extension of the inflammation around 
the old cyst of the abscess. Clonic spasm of the right arm 
as an isolated symptom, without any other disturbance of 
the nervous system, was the opening phenomenon. The day 



42 DISEASES OF THE NERVOUS SYSTEM. 

following the convulsions became epileptic. On the fourth 
day, after a repetition of such convulsions, the right side 
was left partially paralysed. The hemiplegia then gradually 
became complete, and the patient became drowsy and indif- 
ferent, and at length comatose. These symptoms, associated 
with the chronic disease in the lower lobe of the right lung, 
were the basis of a correct diagnosis. 

Case 14 (38). — Encysted abscess in posterior lohe of left cerebral hemis- 
phere ; heart drawn over to right side of chest ; pleuritic adhesions ; ex- 
ternal fistulous opening, and dilated bronchial tubes on the same side. 

J. H — , set. 23, a policeman, who had been in Guy's Hospital a year before 
for pleurisy, was again admitted March 23rd, 1853. His symptoms were 
considered obscure. It was suspected that he might be labouring under 
chronic hydrocephalus. There was mental confusion and loss of memory. 
No paralysis. He was sensible until his death, which took place unexpec- 
tedly April 28th. The account he gave of his illness was, that six weeks 
before admission, whilst on duty, he had a sudden seizure with partial loss of 
consciousness, and the same day a second seizure. After a month he had a 
third seizure. From the time of the first attack he had headache and 
vomiting. 

Post-mortem examination. — No disease of the cranial bones. Membranes 
of the brain healthy. A large abscess in the substance of the white matter 
of the posterior lobe of the left hemisphere, not implicating the thalamus 
opticus. The walls of the abscess were remarkably thick, and in many parts 
mottled with tortuous capillary veins. The whole cyst was easily enucleated 
from the surrounding cerebral substance, which was softened and of an 
opaque white. The walls of the cyst could be divided into three layers ; the 
external layer was finely fibrous and rather loose, and composed of a cellular 
web, the remains of softened nervous tissue ; the middle layer was dense and 
translucent ; it was formed of fine, rather flattened fusiform fibres, with 
elongated nuclei ; the inner layer, or so-called pyogenetic membrane, was 
opaque and brittle ; it consisted of an adherent layer of nuclei and exudation 
cells, many of which were undergoing granular degeneration. The pus 
amounted to about two ounces. It was clotted and mucoid, and decidedly 
alkaline. It contained opaque granules and fibrinous shreds undergoing 
earthy infiltration. The abscess had burst into the descending cornu of the 
lateral ventricle. The surface of the corpus striatum and thalamus on the 
side of the rupture was of a dull colour, but without inflammatory exudation. 
Right lung universally adherent. The lower portion of the pleura thickened, 
and in it a fistulous canal opening externally, but not communicating inter- 
nally with the lung. Pulmonary tissue compressed, the tubes dilated. 
Heart drawn over to the right side by adhesions of the pericardium to the 
lung. Left lung partially adherent. 



ABSCESS OF THE BRAIN. 43 

Remarks. — There cannot in tlie nature of the case be any 
symptoms pathognomonic of abscess of the brain. It is often 
only from the collateral circumstances that we can rightly 
estimate the nature of the cerebral disorder. In this case 
the sudden seizure with partial loss of consciousness, if not 
epileptic, should have caused a suspicion of some local disease 
in the brain. The same symptom has often beeo noticed in 
cases of tumour as well as of abscess. The differential dia- 
gnosis would rest upon the absence of pain preceding and 
following the seizure ; the rapid progress of the symptoms, 
marked by weeks, rather than by months ; the character of 
the cerebral oppression ; and the local conditions of the chest. 
The frequent absence of rigors in cerebral suppuration has 
been already noticed. Although the contents of the abscess 
were undergoing the earthy change there was a gradual ex- 
tension towards the lateral ventricles. 

Case 15 (39). — Inflammatory cysts, with surrounding solid exudation in 
anterior part of right hemisphere of brain, probably excited by contre- 
coup. 

William S — , set. 40, a tall, athletic man, of rather free habits, though not 
a drunkard, by occupation a mill-wright, began to sufEer with severe head- 
ache in the spring of 1854. The pain was principally across the forehead, 
and at times so severe, that, to use his own expression, he thought he should 
go oiit of his mind. He continued at his work until the end of November, 
when his memory became impaired ; he had transient attacks of uncon- 
sciousness, and at other times lost his sight for half an hour or so. He 
had frequently double vision, and was troubled by dark, irregular forms 
creeping before him. From this time he had vomiting and constipation, and 
began to emaciate. January 5th, 1855, he was admitted into Guy's Hospital 
under the care of Dr. Barlow. His manner was dull, he complained of con- 
stant pain in the head, aggravated in paroxysms. There was no paralysis, 
but his movements were sluggish, and he could not stand long without 
feeling faint. Vision impaired. Pupils dilated. Urine scanty, depositing 
phosphates largely when heated. His wife gave an account of a severe fall 
which he had about Christmas, 1853, by slipping upon the pavement and 
striking the back of his head. He was stunned at the time, but the effect 
soon passed off, and the accident was forgotten. He remained in the hos- 
pital until the 24th of February. On several occasions he had seizures iu 
which he lost all muscular power ; these he called faintings. At the 
beginning of April he was readmitted into the hospital. He was then 
totally blind. He could neither walk nor stand, but could move his limbs, 
though he did so tardily, especially on the left side, and remarked that 
"they did not feel the right thing." The left seventh nerve was partially 



44 DISEASES OP THE NEEVOUS SYSTEM. 

paralysed. Tongue projected straight, covered with a thick creamy fur. 
Left to himself he lay continually as if asleep. When aroused he answered 
qiaestions slowly, in a loud, monotonous voice, interrupted by an occasional 
yawn, or dozed off in the middle of a sentence. " Has an awful headache, 
and that's all his complaint." Pupils widely dilated and unaffected by 
light. Urine and fseces the last few weeks passed involuntarily. Occa- 
sional returns of the fainting seizures. He took readily whatever food was 
put into his mouth, but was too dull to feed himself. Deglutition perfect. 
Pulse 64. Respiration 16, tranquil. He lay in a semi-comatose state until 
his death on the 26th. The right pupil was large and fixed, the left smaller 
and unaffected by light, but spontaneously dilated and contracted. There 
were no convulsions. A few days previous to death several bullae formed 
on the legs and ankles, and he became slightly jaundiced. 

Post-mortem examination. — The wasted body of a strongman. Integu- 
ments of a faint yellow colour. A few large blebs on legs and feet. Head 
very large and round, measuring thirty-three inches in circumference. 
Oalvaria very thick, dense, and heav^y. The whole inner surface was vascular, 
and roughened by ossific granulations. The outer surface of the dura mater 
was roughened in correspondence with the bone. Arachnoid slightly opaque. 
The anterior lobe of right hemisphere swollen and pressing over on the left. 
The convolutions flattened. Immediately below the surface a cyst the size 
of an egg, and to its inner side a smaller one. They contained a clear, 
yellow, mucoid fluid, with opaque particles floating in it. These consisted 
of fatty granules, loosely collected together or contained in large, regular 
cells. The larger cyst was round and circumscribed, except on the inner 
side, where it was connected with the smaller one ; this was not so well 
defined. The lining of the larger cyst was smooth, with numerous small 
veins ramifying in it. The walls consisted of yellow solid exudation, part 
fibrillated and part granular, containing exudation-cells and oil-globules 
scattered or grouped tgether. The walls of the smaller cyst were flocculent, 
but presented the same microscopic indications of inflammatory deposit 
undergoing fatty degeneration. The brain-tissue around was yellow and 
soft with vascular striae. The cysts pressed on the right crus cerebri, on the 
second, third, and fourth nerves of the same side, and on the opposite hemi- 
sphere. The inflammatory softening extended to the middle lobe and to 
the outer side of the corpus striatum. The thoracic and abdominal viscera 
healthy, with the exception of recent haemorrhagic infarction of the spleen 
and of the mucous membrane of lesser curvature of stomach. 

Remarls. — This case is given as a connecting link between 
tumour and abscess. The symptoms and chronic course o£ 
the case were such as occur in tumour ; obstinate headache 
continuing for months, followed by double vision and partial 
amaurosis, then vomiting, constipation, and cerebral oppres- 
sion. The mechanical action of the cysts on the surrounding 
structures would obviously be nearly as in tumour. The 



ABSCESS OF THE BRAIN. 45 

difference of the structure of such cysts and of their con- 
tents from those of abscess, is probably one only of degree, 
depending upon the activity of the morbid changes. The 
operation of contre-coup was favoured by the height of the 
man^s stature, and the size of his cranium ; circumstances, 
apparently trifling in themselves, but not to be overlooked 
in estimating the effects of such a fall as he he had. 

Case i6 (40). — Chronic disease of mucous membrane of nose ; partial 
absorption of horizontal plates of ethmoid; inflammation of under 
surface of anterior lobe of brain on right side. 

Thomas "W — , set. 42, employed at the tap of a public house, and of veiy 
intemperate habits. For an uncertain period he had been troubled with 
mucous discharges from the nose, and with vertigo and headache for five 
weeks. Ten days before admission into Guy's Hospital, March 29th, 1855, 
he went to bed in his usual health, and the next morning was found in bed 
insensible. He remained in this state, recovering apparently only the 
slightest glimmering of consciousness, and at the best not able to recognise 
his nearest friends. When first visited, he lay supine and apparently' insen- 
sible. The eyes were open, and directed slightly to the right side. When 
addressed in the loudest voice, no impression was made upon him. Both 
pupils were dilated, the right the larger, and slightly active. Left arm and 
leg motionless. With the right hand he so incessantly rubbed the chest and 
groins that it was necessary to m^^file it to prevent further abrasion of the 
skin, which he had thus already produced. Respiration 16, stertorous, and 
with pufiing out of the cheeks. Pulse 112. There was no alteration of 
symptoms. Towards the end the breathing became quick, short, and entirely 
thoracic. He died April ist. 

Post-mortem examination. — The head only was examined. With the 
exception of a few slight opacities on the arachnoid, the membranes on the 
upper surface of the brain were healthy. The ai-teries and veins were full of 
dark blood. The lateral ventricles were dilated, and contained about an 
ounce of clear fluid. Their surf are (ependyma) gi-anular. Fornix and 
septum lucidum firm. On the under surface of the anterior lobe of the 
cerebi-um, on the right side, from the olfactory bulb backwards to the fissure 
of Sylvius, the membranes were adherent and thickened, and the convolu- 
tions softened. The olfactory bulb itself was slightly enlarged, and con- 
verted into a firm yellowish mass. The grey matter of the convolutions was 
eroded ; the white substance of a yellowish-grey colour. The softening 
skirted the edge of the longitudinal fissure backwards to the fissure of 
Sylvius, so as to affect the under surface of the corpus striatum. The hori- 
zontal plate of the ethmoid was very thin, but not carious. The mucous 
membrane lining the nasal cavities hypersemic, and on the right superior 
turbinated bone it presented an uneven granular surface, but no ulceration. 



46 DISEASES OF THE NEEVOUS SYSTEM. 

Remarks. — This case is introduced as an appendix to Case 
4 (28), to illustrate the extension of disease from the mucous 
membrane of the nose to the membranes and substance of 
the brain without caries of the bone. There was no ulcera- 
tion of the mucous membrane. We may thence conclude 
that the changes in the capillaries through which the morbid 
action is distributed, may be independent of any destructive 
action in the tissues. In gonorrhoea, the capillaries and 
their contents propagate the morbid action without ulcera- 
tion. General phlebitis may occur from simple sprain of a 
joint without any lesion of the skin or tearing of deeper 
parts. 



ABSCESS OF THE BRAINJ 



WILLIAM W. GULL, M.D., and HENRY G. SUTTON, M.B. 



Abscess of the Brain is comparatively a rare disease^ and 
it falls to the lot of no man to see a great many cases. We 
have collected seventy-six cases in all from various sources, 
and the details in this paper are based upon these records. 
Many of the cases have not before been published. We 
have arranged the different parts of this subject in the fol- 
lowing order : — A description of the various conditions that 
are known to give rise to cerebral abscess, the morbid 
anatomy, the symptoms, pathology, diagnosis, and treat- 
ment. 

Suppurative inflammation of the brain may be caused by 
injury to the head, especially where the skull is fractured 
and the brain contused. Mr. Prescott Hewitt says : — " All 
traumatic inflammation of the brain substance may end in 
suppuration and abscess.^' 

Cerebral abscess may follow a penetrating wound of the 
brain substance, by a knife, by a splinter of wood, or by 
some sharp instrument being forced through the skull 
(Case 74). 

Abscess of the brain may follow a fracture of the skull 
where there is no displacement of the bone ; acute suppura- 
tive inflammation of the membranes and brain substance 

^ Reprinted from Reynold's 'System of Medicine,' vol. ii, 1868, by 
permission of Dr. Russell Reynolds and Messrs. Macmillan and Co. 



48 DISEASES OF THE NERVOUS SYSTEM. 

being set up by tlie injury (Case i). In many cases, caused 
by fracture of the skull, the abscess in the brain is seated 
immediately under the injured bone, and close to the surface 
of the hemisphere. In others the abscess is not seated 
near the surface ; for instance, a person may receive a frac- 
ture of the skull, symptoms of compression may set in, and 
the skull may be, in consequence, trephined ; the portions 
of depressed bone may be removed, and the patient go out 
of the hospital apparently well. But after a few weeks or 
months, cerebral symptoms may again appear, and the 
patient may die, and the autopsy reveal an encysted abscess 
embedded in the substance of the brain, and seated at some 
distance from the surface (Case 2). 

Cerebral abscess may follow an injury to the skull, where 
there is no fracture of the latter, and with (Cases 15 and 53), 
or even without, a scalp wound. In such cases the injury 
excites inflammation and suppuration of the diploe of the 
bone, and the suppuration extends and involves the brain. 

Cerebral abscess may follow contusion, or, as it is some- 
times expressed, concussion of the brain, without there being 
any fracture or other discoverable injury to the skull. Mr. 
Prescott Hewitt says that he has seen two cases of this kind, 
and the abscesses were large.^ 

This is a very important class of cases, for it probably 
embraces not a few of the so-called idiopathic abscesses of 
the brain. 

In two of our cases, abscess was found in the brain, 
though in neither was there any evidence to show that the 
skull had been fractured or otherwise injured. With both 
patients the symptoms followed directly after the injury ; 
one had a fit on the same day as the accident, and the other 
suffered from almost constant pain in the head for a 
fortnight after the accident, and was otherwise generally 
indisposed. The abscesses were encysted in both instances, 
and, during the time they were forming, there were sym- 
ptoms indicative of cerebral disease, although, in the second 
case, the symptoms wei'e, for a while, obscure. One patient 
died seven weeks, and the other three months, after the 
accident. 

' 'Holmes' Surgery,' vol. ii, p. 185. 



ABSCESS or THE BRAIN. 49 

Cases might be given to show that abscess may follow 
injury to the head; without any fracture or other discover- 
able injury to the skull (Cases 7, 13, 20, 35, 39, 43) ; and 
the abscess may remain latent for months or even longer. 

One of the commonest causes of cerebral abscess is 
disease of the internal ear. The clinical history of this 
class of cases is usually as follows : — The patient has a dis- 
charge from the ear for some time — for months — and, in 
many cases, for years ; the dischai-ge being continuous or 
intermittent. It is common to hear it said that the dis- 
charge began in childhood, after an attack of measles, 
scarlatina, or smallpox ; and since has returned, more or 
less. With the discharge there is often deafness and pain 
in the ear, but more often the patient makes no complaint 
of either. In some cases the discharge is very offensive, 
and has been so for some time past. The extension of the 
disease to the brain is often very insidious. There may be 
no indications that the brain has become seriously involved 
until acute symptoms set in a few days before death. Very 
often the first sign is a great increase of the pain in the 
ear. The pain is often very severe, and comes on in 
paroxysms, so violent in some cases, that the sufferer 
screams with it. Occasionally the acute mischief in the 
brain is ushered in with rigors ; at other times with nausea 
and vomiting. 

Sometimes an epileptiform convulsion ushers in the acute 
symptoms, and a few days after this the convulsion is 
repeated, and followed by hemiplegia. 

The accession of acute symptoms appears, in many cases, 
to correspond with the commencement of acute inflammatory 
softening, either primarily in healthy brain, or secondarily 
around an old abscess. Then the skin becomes hot, the 
pulse quick, tongue dry and parched, great prostration, 
drowsiness and stupor set in. Such symptoms as resemble 
continued fever, and have been mistaken for it in some cases. 
The discharge from the ear varies very much during the 
acute symptoms. It is common for it to subside, or even 
entirely to disappear. 

Chronic changes, dependent upon disease of the internal 

4 



50 DISEASES OF THE NERVOUS SYSTEM. 

eai% may be insidiously going on in the brain substance, 
without there being any symptoms of cerebral disease. 
1311 Mr. Toyubee was of opinion that the inflammation 
extends to the brain, from the pus not escaping from the 
cavity of the tympanum extei'nally. He says : " So long as 
there is a free exit for the discharge, I believe the disease 
rarely extends to the brain." ^ He also remarks: "In all 
fatal cases the discharge has been deprived of a free egress." 
Mr. Toynbee fui-ther states, in cases where the disease 
attacks the mastoid cells in early life, the cerebrum is the 
part of the brain which is most likely to suffer, while in 
later periods of life the cerebellum is the part most 
generally affected. Long experience has clearly shown, 
that, when disease of the internal ear has gone on for 
a long time, the temporal bone is very liable to become 
diseased. When the patient dies with cerebral symptoms, 
it is common to find caries of the petrous, or mastoid 
portion of the temporal bone. It is also common to find 
suppurative inflammation of the dura mater covering the 
diseased bone, with or without sloughing of that membrane. 
There is, in some cases, no direct extension of the disease 
from the bone to the contiguous parts. In such cases the 
bone, membranes, and surface of the bi*ain, are healthy. 
A portion of healthy brain may lie between the abscess and 
the bone. The diseased action is considered to extend by a 
vein. It is rare to find abscess of the brain following acute 
disease of the ear ; but one case is alluded to by Mr. Toynbee. 

In cases of chronic disease of the ear, the causes of the 
acute brain mischief are various. A blow on the head, 
violent exercise, or other depressing influence ; also cold 
air, or some irritating application, is sufficient to engraft 
acute changes upon the chronic disease. 

Cerebral abscess may be associated with, and apparently 
dependent upon, chronic disease in the lungs ; but in two 
of our cases the morbid appearances were such as to indicate 
acute changes in the lungs, extending, howevei', over several 
weeks (Cases 9 and 57). 

In a case that occurred in St. Bartholomew's Hospital, 
the lung presented the appearance of acute pneumonia in 
• Vide ' Diseases of the Ear,' by Mr. Toynbee, p. 303. 



ABSCESS OF THE BRAIN. 51 

the third stage ; but the symptoms indicated that the disease 
had been going on about two months and ten days (Case g). 

In all the other cases, which have come under our notice, 
the morbid changes in the chest had evidently been going 
on several months and even years (Case 38). In one there 
was a large suppurating chronic empyema (Cases 10 and 11). 
In another there was a large cavity at the apex of the right 
lung, which was firmly adherent to the chest walls by a 
thick layer of indurated tissue. Another patient had had 
flattening and general contraction of the left chest for years, 
signs of dilated bronchial tubes, and of disease in the left 
lung (Cases 36 and 38). 

Suppuration in any part of the body may give rise to 
secondary abscess in the brain. In one of our cases there 
was an abscess in the sheath of the left rectus abdominis 
muscle, and several abscesses without cyst in the brain 
(Case 32). In this case it is instructive to notice that the 
lungs, the common seat of pyemic abscesses, did not con- 
tain any abscesses, nor were there any in the liver or spleen. 
In another case there were py^emic abscesses in the brain 
(Case 33), apparently the result of chronic suppuration of a 
mesentericgland, and co-existing recent abscesses in the spleen 
and kidney. In a case of acute necrosis of the tibia (Case 4), 
which occurred in St. Thomas's Hospital, there w^ere numer- 
ous abscesses in the brain, and pytemic abscess in the lungs, 
liver, and spleen. In a case given by Dr. Bright, a whitlow 
was the source of general pyaemia and abscess of the brain. 
In another case, referred to by Lebert, the drawing of a 
tooth was follow by inflammation of the upper part of the 
face and cerebral abscess. Dysentery was the cause in one 
instance (Case 25) ; abscess near the uterus (Case 8) ; sup- 
puration in the Fallopian tube (Case 75) ; carcinoma of the 
face (Case 50) ; abscess in the liver (Case 51) ; and the phage- 
dsenic ulceration, following amputation of the breast (Case 56), 
were the causes in other cases. Dr. Ogle relates a case of 
secondary purulent deposit in the brain, apparently the 
result of ulceration of the coecal appendage. There is also 
another recorded case following amputation of the forearm. 
> From analogy we should expect that an hydatid tumour, or so-called 
-strumous deposit in the brain, would cause abscess. We have, however, no 



52 DISEASES OF THE NERVOUS SYSTEM. 

In clironic disease of the bones of the nose, and in cases 
of syphilitic disease of the bones of the skull, there is a lia- 
bility to cerebral abscess (Case 41), 

Morbid Anatomy. — An abscess may form in any part of 
the brain. Usually it forms in the white substance, and 
when in the grey it is formed by extension from the white. 
The middle cerebral lobes are the most frequent seats of 
abscess. One hemisphere is as frequently attacked as the 
other. Of 80 cases, abscess was situated in the left hemi- 
sphere in 22, and in the right in 29. Practically, therefore, 
one hemisphere would appear to be as liable to be attacked 
as the other. In 1 2 cases abscess was situated in the middle 
lobe, but it is not stated in which hemisphere. The middle 
lobes were the seat of abscess in 23 out of 74 instances. 
Abscess was found in the cerebellum in 13 cases, in the pons 
Yarolii twice, in the corpus striatum twice, in the optic 
thalamus twice. Abercrombie mentions an instance of 
abscess in the medulla oblongata. In several of the 74 cases 
the abscesses were multiple, and found in more than one part 
of the brain. The appearance of the abscess varies according 
to its duration. If it have been recently formed the pus is 
not inclosed in a cyst, but directly surrounded by ragged 
suppurating brain tissue, and there is not a trace of lining' 
membrane to the cavity. If the abscess have been formed 
some time the pus is inclosed in a cyst of variable thickness. 
In very old abscesses the cyst wall has been found a quarter 
of an inch, or more, in thickness. "When the abscess is a 
few weeks old the cyst wall is usually a line or two in thick- 
ness. The wall of the cyst is formed of fibro-celiular ele- 
ments, and, in some cases, well-formed spindle-shaped fibres 
are seen ; in others the fibro-cellular tissue has undergone 
granular degeneration, and the fibre cells are very indistinct. 
The cyst, when of old date, may be divided into three parts 
— an outer layer, which is made up of loose fine fibrous 
tissue ; a middle layer, which is firmer and more coarsely 
fibrous than the outer ; and the inner surface of the cyst is 
formed by a smooth, pyogenic membrane, in which some 

record of sucli a case. Abscess is also said to have occurred when the carotid 
artery was tied. Probably it was softening of the brain, and not abscess. 



ABSCESS OF THE BRAIN. 53 

small irregular dilated veins may be seen running in differ- 
ent directions. 

In abscesses of recent formation, the pus is generally of 
a greenish hue, and may, or may not, have a disagreeable 
smell. In old abscesses the pus is green, foitid, mucoid, 
and is decidedly alkaline. The pus removed from old ab- 
scesses, when placed under the mici'oscope, shows few or no 
well-developed pus corpuscles ; there is a large quantity of 
granular fat and granular matter without any nuclei. 

There may be several encysted abscesses in the brain. In 
one of our cases there were no less than four ; in another a 
large encysted abscess in each hemisphere. 

The condition of the brain substance immediately' around 
the abscess may vary very much ; it has commonly under- 
gone a process of softening*. Rokitansky, speaking of recent 
abscess, says, round the abscess the brain substance is in a 
state of inflammation, producing red softening, yellow soft- 
ening, and in more distant parts oedema of the brain tissue. 

When a large abscess is situated in one of the hemispheres, 
the bi'ain is often altered in shape ; the convolutions being 
packed together and flattened ; the hemisphere bulged at 
the side, and if the abscess be very large, the hemisphere 
containing it may feel more like a bag of pulpy thick fluid 
than solid brain substance. Collections of pus in the hemi- 
.spheres tend to make their way towards, and discharge 
themselves into, the lateral ventricles, or on the surface of 
the brain. Pus, like blood, may fill one lateral ventricle 
only, or escape into the ventricle on the opposite side. In 
abscesses, as in very vascular, soft, gliomatous tumours of 
the brain, ha3morrhagic effusions are occasionally met with, 
and a coagulum of blood may be seen surrounded by 
pus.^ 

We have already stated that several abscesses may exist 
together in the brain ; this is common when the patient has 
died of pyemic cerebral abscess. In such cases every part 
of the brain may be studded with minute collections of pus ; 
they may be found in the cerebrum, in the cerebellum, in 
the optic thalamus, in the corpus striatum, and pons Varolii. 
The size of these abscesses may vary from a pin's head to a 

' See ' Guy's Hospital Reports,' vol. iii, 3rd series, Case No. 6, p. 291. 



54 DISEASES OF THE NERVOUS SYSTEM. 

hazel-nut, or even larger. They are usually situated near 
the surface of the brain. The cerebral substance around 
these pyasmic abscesses may be softened, at other times it is 
firm and comparatively healthy. When abscess of the brain 
is dependent upon disease of the internal ear, the morbid 
appearances are much as follows : — the dura mater, situated 
over the diseased petrous or mastoid portion of the temporal 
bone, is often found highly congested, softened, and ulcerated; 
or of a dirty green colour, and evidently sloughing, and the 
bone laid bare. In other cases the dura mater is simply 
thickened and covered with pui'ulent lymph, and betwixt the 
dura mater and the bone there is often a collection of pus. 
The lateral sinuses are frequently involved and plugged, 
especially when there is disease of the mastoid cells ; the 
sinus is often seen enveloped in pus and pui'ulent lymph. 
The suppurative inflammation may extend along the internal 
jugular vein, and set up suppurative pleuritis and abscess in 
the lung. 

In abscess of the brain due to disease of the ear, there is, 
in the majority of cases, caries of the temporal bone ; the 
latter is seen of a dark colour, with an irregular roughened 
surface. The abscess in the brain may have direct com- 
munication with the diseased bone, and the contents of the 
abscess make their way through the ulcerated openings in the 
dura and bone into the typanum, and then escape through 
the perforated membrane tympani into the external meatus, 
thus constituting what has been termed ''otorrhoeacerebralis." 
A similar communication and escape of the pus is said to have 
occurred in cases of abscess in the brain caused by diseased 
ethmoid bone. At other times there is no such direct com- 
munication, for there is a layer of brain substance separating 
the abscess from the membrane of the brain. This layer is 
often softened, of an ash grey or yellowish appearance, and 
looking as if the pus was about to burst and discharge itself 
on the surface of the brain. 

In some cases of abscess dependent on disease of the 
internal ear, there is no caries of the bone, as we have 
already mentioned ; the membranes may be healthy, and the 
abscess may be situated at a distance greater or less from 
the surface of the brain. 



ABSCESS OF THE BRAIN. 55 

Symptoms. — In 73 cases of abscess of the brain, the sym- 
ptoms were as follows : — Pain in the head in 39 cases ; epi- 
leptiform seizures in 38 ; coma in 30 ; heaviness, stupor, 
and drowsiness in 30 ; paralysis in 24 ; rigors in 1 7 ; pyrexia 
in 13 ; delirium in 13 ; vomiting in 12 ; incontinence of urine, 
or of faeces, or both, in 15 ; vertigo in 8 ; disordered sensi- 
bility, not including pain in the head, in 6 ; defective ai'ticu- 
lation in 4 ; defective sight in 3 ; an apoplectic attack in i . 

That some of the symptoms may have existed in greater 
proportion, we should be prepared to expect, especially such 
symptoms as vertigo, pyrexia, emaciation, and probably, in a 
greater number of cases, defect of sight would have been 
discovered had the eye been tested. The symptoms, there- 
fore, that are most frequently observed in cases of abscess 
in the brain are pain in the head, epileptiform attacks, para- 
lysis, coma, heaviness, drowsiness, stupor, rigors, pyrexia, 
delirium, vomiting, and incontinence of urine and faeces. 
In a few cases defective articulation was met with. The 
records show that the intellect was very little affected. 
Paralysis was observed in 24, that is in about one third, 
whereas in Lebert's cases it was observed in about one half. 
He included, however, not only local paralysis, but also 
general loss of muscular power, whereas we have confined 
the term to local paralysis only, such as loss of power on one 
side of the body, of one arm or leg, one side of the face, 
or some other part. 

The first symptom, in many cases, is pain in the head ; it 
may be the only indication of cerebral disease present for 
months. The pain is often very agonizing. 

An intense neuralgic pain situated over one spot is occa- 
sionally the first symptom ; sometimes the pain is seated 
almost immediately over the region of the abscess. A boy 
having an abscess in the anterior lobe of the right hemi- 

1 One patient lay in bed continuously holding his head with both his 
hands ; another walked about with his hands pressed against one side of his 
head, crying out constantly, " Oh ! my head ; oh ! my head." The pain is 
often so severe that the patients shriek from the agony they suffer. A 
patient, who was perfectly sensible, said he coiild not help screaming; and, 
although he tore and bit anybody or anything near him, he at the same 
time expressed contrition for what he was doing, and said the pain in his 
head was unbearable ; it felt as if someone was knocking it with a hammer. 



56 DISEASES OF THE NERVOUS SYSTEM. 

sphere, complained of almost constant burning pain over 
the front and right side of the head, but this localisation of 
pain over the seat of the abscess is by no means constant. 
In some cases the pain is very remote. In one patient there 
was an abscess in the cerebellum, and the pain was felt in 
the forehead ; in another there was an abscess in the right 
middle cerebral lobe, and the pain was referred to the left 
side of the head. 

The pain often comes on in paroxysms ; in other cases it 
is continuous, remittent, or intermittent. It is not present 
in all cases of cerebral abscess, as the statistics of our 76 
cases show. It is very commonly associated with pain in 
the ear, when the abscess is due to disease of the auditory 
apparatus. 

Instead of pain preceding, it may follow the convulsive 
attacks. Cases of this kind are by no means few. 

Occasionally the first indication of cerebral mischief is a 
sudden aud unexpected epileptiform seizure. The epilepti- 
form seizures are occasionally the most prominent symptoms 
from the time of seizure to the patient's death. The epi- 
leptic attacks do not necessarily come on every day ; occa- 
sionally some days elapse between the seizures. 

After each convulsion the side affected is often left weak, 
and this increases until there is complete hemiplegia. The 
convulsive movements are sometimes unattended with insensi- 
bility, and are confined to one extremity, especially the ai'm. 
This had been long noticed. 

Abercrombie alludes to a case of Lallemande's, m which 
there was pain in the right side of the head and tremor of 
the left arm. This was followed by continued convulsions, 
flexion, and extension of the left arm, which after some days 
ended in palsy. 

Instead of convulsive moveuients, the first indications of 
brain disease may be numbness and tingling in one ex- 
tremity. 

The symptoms in other cases of cerebral abscess are like 
those that are said to indicate cerebral softening. There is 
sudden loss of power on one side of the body without any 
loss of consciousness ; the leg being less affected than 
the arm. 



ABSCESS OP THE BRAIN. 57 

In several instances rigors were very prominent symptoms 
throughout the attack. A patient, suifering from suppura- 
tion, was noticed to be getting thinner and weaker ; when he 
was seized with rigors, diarrhoea, a dry brown parched tongue, 
and a hot skin, he became comatose and died. Pyemic 
abscesses were discovered in the brain. 

In some cases of pyeemic abscesses there are no special 
symptoms to show that organic disease is going on in the 
brain ; but only the general indications of pyasmia. In others 
the accession of convulsive seizures, pai-alysis, or coma, indi- 
cates disease in the cerebral organ. Rigors so severe were 
noticed in a few instances, and returned w4th such regularity 
every day, that they closely resembled those of ague. One 
patient had headache, rigors, and vomiting, returning every 
day for five days, and then became unconscious. Rigors do 
not occur, in some instances, until after convulsive seizures 
have indicated cerebral mischief. Imperfect articulation, to a 
marked degree, was noticed in some cases, and in one there 
was loss of language. 

With respect to the eye. Dr. Hughlings Jackson has 
mentioned to us that he has seen changes in the retina (optic 
neuritis ?) in a case of cerebral abscess. Dr. Jackson thinks 
such changes are common to several kinds of cerebral 
disease. 

Mental disturbances were observed in some cases. Now 
and then the only symptoms noted were a heavy expression, 
a disinclination to speak, and indifference to surrounding 
objects. In some cases with disease of the ear, it was 
stated that the patients had attempted to commit suicide. 
One patient appeared to become hypochrondrical. Emacia- 
tion setting in rapidly was a marked symptom in several 
cases. Similar emaciation is seen in some cases of tumour 
of the brain ; but is not so frequent as in abscess. 

Patients suffering from cerebral abscess may have sym- 
ptoms so closely resembling continued fever, that it is ex- 
ceedingly difficult, if not impossible, with any degree of cer- 
tainty, to say whether it be a case of fever or of oi'ganic 
disease of the brain. 

Pathology. — Cerebral abscess may be produced by direct 
injury, or by contre-coup ; contusing or lacerating the 



68 DISEASES OF THE NEKVOUS SYSTEM. 

nervous tissue^ and setting up inflammation and suppuration. 
It may be produced by suppurative inflammation in some 
tissue in tlie neiglibourliood of the brain which, spreads to a 
contiguous part ; namely, in the ear or nose, which extends, 
and invades the dura mater, pia mater, and brain substance. 
Or the diseased action may spread by continuity of structure, 
as along a vein, and thus to the brain. Disease of the eai', 
nose, or of other cranial bones, may give rise to cerebral 
abscess in this manner. Again, abscess may be produced 
where there is disease of the cranial bones, or some growth 
involving them, by the veins communicating with the dis- 
eased bone becoming plugged. The process of coagulation 
extends and invades the veins communicating with the 
sinuses of the dura mater. These become plugged, as also 
the veins of the pia mater, and probably some branches 
entering the brain tissue also, and inflammation, terminating 
in suppuration, is thence set up in the brain. In other 
cases minute coagula, or thromboses, are supposed to be 
detached and carried along by the circulation until they are 
arrested in the capillaries of the brain, and often of the 
lungs, kidneys, and other organs. 

Pygemic abscesses are occasionally found in the brain, and 
not in any other organ of the body. Besides the coagula, 
some of the elements of pus may be carried by the circula- 
tion to aid in, or be the means of, setting up suppuration 
in the parts where the thrombosis is arrested. In this wa}' 
abscesses in the brain are probably caused by abscess or 
suppuration in the liver, lungs, bowels, or in other parts. 

We next enquire if every form of cerebral inflammation, 
or encephalitis, no matter what its origin, be liable to end 
in suppuration and an abscess. It has been many times 
stated that such is the case ; but it would appear that the 
inflammation must be set up by a special cause, and unless 
it be so, it does not end in suppuration and abscess. Sup- 
puration may apparently be excited by local injury or by 
the elements of pus or thrombosis ; but experience shows 
that other forms of inflammation do not terminate in abscess. 
For instance, encephalitis and softening, the result of plug- 
ging of a cerebral artery, or encephalitis around a hsemor- 
rhagic effusion, or around a gliomatous tumour or old cyst, 



ABSCESS OF THE BRAIN. 59 

shows no disposition to tlie formation of pus or abscess. 
The brain may soften, disintegrate, and a cyst may be formed, 
but there is no pus formed. 

It is necessary, now, to ask if there be not good evidence 
to show that the brain may be the seat of suppurative in- 
flammation and abscess without there being any cause to 
account for it ? Is there not, in such cases, idiopathic in- 
flammation which gives rise to idiopathic abscess ? By 
idiopathic cerebral abscess, we suppose, is meant abscess 
which is not preceded or occasioned by injury or disease ; 
its origin being unaccounted for. Lebert and others admit 
the occurrence of idiopathic cerebral abscess. Such cases 
are, however, in comparison with others, rare. It is beyond 
all doubt that a certain number of cases of cerebral abscess 
do occur in which no disease is discovered in any other part 
of the body, and there is no history of any recognised cause 
to account for the cerebral abscess. 

Before, however, it be concluded that abscess has been 
formed idiopathically, it is necessary to remember that in the 
majority of cases there is a cause to account for the forma- 
tion of such abscess, and that only in a very small minority 
have observers failed to find some admitted cause. In the 
face of such evidence, is there not good reason to think that 
in this small minority of cases, the primary cause has been 
overlooked ? And, when it is still further remembered that 
hours have been passed in searching for the primary disease 
or cause, and at last it has been found limited to a mesen- 
teric gland, a gumboil, or a whitlow^ — in fact the primary 
disease was so small, that it might have been very easily 
overlooked — it appears to us not difficult to understand how, 
even after very great care, the primary cause may have re- 
mained undiscovered. Bearing all this in mind, we recog- 
nise that in a few cases of cerebral abscess, the cause cannot 
be discovered ; but even when the cause is undiscovered, 
we should not assume that the suppurative inflammation has 
commenced idiopathically in the brain. 

Cerebral abscess proves fatal in many cases, not by a col- 
lection of pus in one or other part of the brain, but by exten- 
sive inflammatory softening around the abscess, involving 
vital parts of the brain ; and it is from such softening that 



60 DISEASES OF THE NERVOUS SYSTEM. 

the abscess is able to make its way towards tbe ventricles or 
the surface of the brain. The softening around very old en- 
cysted abscess would appear not to be set up by pyogenic 
changes going on in the lining membrane^ for there is not 
a large quantity of well-formed pus corpuscles in old en- 
cysted abscesses to show that such active changes have been 
going on in this membrane. 

The softening would rather appear to be due to some cir- 
cumstance interfering with the nutrition of the parts outside 
of the abscess, but in its neighbourhood. The nutrition of 
such parts, owing to the presence of a foreign body, being 
very feeble, it is easy to understand how a blow on the head 
or a debilitated or cachectic state of the system may be 
sufficient to excite such feebly nourished parts to take on 
acute inflammatory softening. 

Has abscess in the brain any tendency to spontaneous 
cure ? Lebert thinks not, and when we remember that 
there is no well-established case on record, showing that an 
abscess has been spontaneously cured, we readily admit that 
the evidence very strongly favours the belief that cerebral 
abscesses do not tend to a spontaneous cure. It is, however, 
necessary to remember that the brain is a very vital organ, 
severely taxed in our every-day labours, and, if not sound, 
its functions, which are essential to life, may be brought to 
a stop. When there is an abscess in the brain, the organ 
being unsound, its functions are very liable to be perverted, 
and death follows ; whereas, if the abscess were seated in an 
organ less essential to life, any perversion of its functional 
activity would not be attended with fatal results, and thus 
time would be gained for the abscess to pass through the 
different stages essential for its cure. We may therefore 
ask ourselves whether it is that an abscess of the brain has 
no disposition to spontaneous cure, or whether it is that the 
patient does not live long enough for such a process to be 
accomplished ? The development of a firm cyst wall would 
show that there is a disposition to spontaneous cure. The 
cyst wall is a protective effort that the brain makes to 
localise the mischief and protect the sound from the diseased 
part. And experience has shown that time is only required 



ABSCESS OF THE BRAIN. 61 

for sucli protecting effoi-ts to be very great, and for the 
barrier guarding the pus to become stronger and stronger. 

We are next led to ask, is there any thing in the condi- 
tion of the pus discovered in old absceses to show that these 
were in a process of cure ? To our minds, there is. It is 
usual to find such pus in a vei*y degenei'ate condition, viz. 
granular and fatty, which is favourable to its absorption and 
concretion ; such changes as occur in abscesses that have 
undergone spontaneous cure. This is no idle question. It 
is simply — Is cerebral abscess necessarily a fatal and incur- 
able disease ? Practically it is ; but there is nothing in its 
morbid anatomy to lead us to conclude that it is necessarily 
incurable. 

Diagnosis. — Cerebral abscess is inferred when there are 
symptoms of the brain indicative of organic disease, and 
there are present those morbid conditions that are known to 
give rise to cerebal abscess, such as a discharge from the ear, 
nose, or chronic suppuration elsewhere, or when there is a 
history of a blow, or of some other acknowledged cause of 
the disease. No doubt that in some cases the inference 
proves correct, where there is evidence showing that the cere- 
bral substance is undoubtedly diseased, and further evidence 
of suppuration going on in some part of the body ; for here 
there are indications of acute brain disease, and we are led 
to suspect that this is due to abscess, since such causes are 
present as ai'e known to produce it. With the brain, how- 
ever, as with other organs, we are more often able to say 
that it is diseased than to say what is the precise nature of 
the pathological changes going on in its substance. 

There may be evidence to show that a patient has chronic 
disease of the nose or ear, and cerebral symptoms may super- 
vene suddenly ; epileptiform seizures and other symptoms 
may be present, such as are seen in cases of cerebral abscess ; 
the patient may die, and yet there may be no disease of the 
brain or of its membranes. In some cases the membranes 
alone are diseased ; in others the brain substance is softened 
without abscess. Disease of the bones of the skull, no 
matter whether it be fracture, syphilitic disease, or a growth, 
is liable to set up inflammation of the membranes of the 
brain, and the inflammation may spread and give rise to 



62 DISEASES OF THE NERVOUS SYSTEM. 

suppurative inflammation of the brain substance. If the 
patient survive six or seven weeks, an abscess may be 
formed ; if he die in two or three weeks after acute sym- 
ptoms have set in, the brain may be found softened, but with- 
out abscess. Not unfrequently death takes place before there 
is time for the suppurative inflammation to form an abscess. 

There may be a history of injury to the head, cerebral 
disease may appear to have followed as a consequence, and 
the post-mortem examination reveal disease in the brain, but 
not abscess. 

Injury may be followed by the formation, not of an abscess, 
but of a tumour, malignant disease, or by softening in the 
brain ; or further, the disease may not be in the brain at all, 
but on the surface. Experience has shown that an injury 
to the head may produce a large cj^st in the cavity of the 
arachnoid, and the symptoms of the case may be similar to 
what are seen in cases of encysted abscess. 

A history of a blow on the head, followed by severe pain, 
loss of energy, altered manner, fits, and partial hemiplegia, 
occurs in abscess, but also in other cerebral diseases as well 
as abscess. 

Cerebral symptoms, associated with offensive discharge 
from the ear and nose, would lead one to suspect abscess in 
the brain ; but in one of our cases there was tumour, and not 
abscess. The co-existence of tumour in the brain, with the 
conditions that are known to produce abscess, makes the 
differential diagnosis extremely difficult. There are no 
pathognomic symptoms of abscess nor of tumour. It is only 
the different manner in which the symptoms are grouped, 
and the existence of those conditions that are known to 
produce one and not the other disease, which leads the prac- 
titioner to suspect that there may be tumour rather than 
abscess, or vice versa. 

The symptoms of abscess may differ from those of tumour 
m the following respects. In abscess there is often marked 
cachexia and great emaciation. In tumour the patients have 
often no marked cachexia, even look healthy, and the body is 
fairly nourished, certainly not emaciated. In abscess the dura- 
tion of the cerebral symptoms is generally much shorter than in 
tumour. The symptoms in abscess are usually either latent or 



ABSCESS OF THE BRAIN. 63 

acute ; in tumour they are often clironic. In the latter there 
may be local paralysis extending over several months, which 
is very rare in abscess. The intra-cranial nerves are much 
more frequently affected in tumour than in abscess. Occa- 
sionally, however, a person with tumour is seen to be much 
emaciated. These differences may enable the practitioner, 
in some cases, to diagnose one condition from the other, but 
in neither case are these differences so constant that a certain 
diagnosis can be made. 

An abscess may lie latent in the brain for many months, 
and then acute symptoms may suddenly set in, and the 
patient die in a few days. The same thing may take place 
with respect to cerebral tumour. Experience has shown that 
cancerous deposits also may exist in the brain without there 
being any decided cerebral symptoms. 

Chronic encysted abscesses and tumours of the brain have 
many symptoms in common. An hydatid tumour, glio- 
matous tumour, a cyst, cancerous deposits in the brain, or 
any other substance acting as a foreign body, may produce 
pain in the head, epileptiform seizures, with or without para- 
lysis, optic neuritis, vomiting, or gradual loss of muscular 
power. 

We are often able to say, when there is acute per- 
sistent but variable paralysis, with pyrexia, that there is 
acute inflammatory softening of the brain ; but whether that 
softening is going on around an abscess, a tumour, or a cyst, 
or whether excited by disease situated on the surface of the 
brain, we may be unable to give any exact opinion. 

With respect to rigors in cases of cerebral abscess, we 
have already stated that they are very well marked in some 
instances, and may be not unlike those of ague. This sym- 
ptom is not, however, peculiar to cerebral abscess. It occa- 
sionally occurs in other forms of brain disease, for instance, 
as gliomatous tumours or tubercle. 

Treatment of abscess of the brain should be by anticipa- 
tion — obviating the causes which lead to it ; in chronic 
disease of the ear or nose, by maintaining a free exit for the 
discharge, no matter what the exciting cause. Rest is the 
most important part of the treatment, avoiding thereby both 
mental and mechanical excitement. 



64 DISEASES OF THE NERVOUS SYSTEM. 

By a simple diet and quiet life abscess may be dormant in 
the brain for an indefinite time.^ 

In cases were abscess follows injury to the head^ surgical 
interference must be thought of. The principle in such 
cases is a mechanical one, namely, to reach the abscess and 
evacuate its contents, if that be thought advisable ; expe- 
rience has but little to commend it. 

^ This is, however, to be observed that encysted abscess of the brain is 
fatal from changes outside the cyst of an acute kind, such as might be pre- 
sumed to be preventible to a great extent. In support of this opinion we 
may say that, in our experience, we have known abscess lie quiet for months 
after a blow on the head, and the patient and the medical attendant become 
confident that all was well, the symptoms of lesion having slowly gone off ; 
and yet a fatal issue be produced after a few hours' suffering by neglecting 
the precaution of rest and regimen. Probably such rest and care should be 
continued, not for months only, but for years. This we say from clinical 
observations of the changes in the cyst of old cerebral abscess. 



ABSCESS OP THE BRAIN. 



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CASES 



ANEUKISM OF THE CEREBRAL VESSELS/ 



Aneurism of the cerebral vessels has been regarded as a 
disease of extreme rarity^ and judging by the scanty records 
of it, we should conclude that the opinion was true. This 
apparent rarity, however, like all negative conclusions, is 
doubtful, and I think there is the more reason to suspect it 
as only apparent, and due to careless inquiry, since the 
discovery of these cases has been much more frequent 
during the last ten years. There are several reasons why 
intracranial aneurism is likely to be overlooked. First of 
all, as here hinted at, it has not been looked for, and it is 
notorious that the eye can see only that it brings with it 
the aptitude to see. Again, when death occurs from 
rupture of the sac, recent coagula may so imbed and con- 
ceal it that unless strictly looked for it will not be found, 
for the sac is often small and thin and transparent, except 
at the point of rupture. Further, also, when death has 
taken place from changes around the aneurism, as by pres- 
sure or softening, the sac itself may present such appear- 
ances that unless a minute dissection be made of it, its true 
nature may not be discovered. Whenever young persons 
die with symptoms of ingravescent apoplexy, and after death 
large effusion of blood is found, especially if the effusion be 
over the surface of the brain in the meshes of the pia mater, 
the presence of an aneurism is probable. 

• Reprinted from the 'Guy's Hospital Reports,' vol. v, 1859, p. 281. 



ANEURISM OP THE CEREBRAL VESSELS. 87 

Though intracranial aneurism generally occurs on the 
larger trunks of the vessels as they lie at the base of the 
brain, or in the fissures between its lobes, the smaller 
branches, after entering the cerebral substance, are not 
exempt. Dr. Crisp records the case of a boy, aged four- 
teen, who died from rupture of one of two small aneurisms 
on the anterior cerebral artery in the substance of the ante- 
rior lobe. In the seventh volume of the ' Pathological 
Transactions ' is a case by Dr. Van der Byl, where an 
aneurism on the posterior cerebral artery lay in the sub- 
stance of the brain, as a tumour of the size of a hen's egg, 
composed of concentric layers of fibrin. In one of the 
cases given below (see Plate), it will be seen that death was 
occasioned by the rupture of a very small aneurism in the 
substance of the pons Varolii. This was found by hardening 
the brain-substance in spirit before removing the coagulum. 

We are indebted to Dr. Brinton for a table of fifty-one 
cases ^ of intracranial aneurism, from which it appears that 
the most frequent seat of the disease is the basilar artery, 
and next the middle cerebral of either side. If to the 
cases in Dr. Brinton's table be added eleven others, four 
from the seventh volume of the ' Pathological Transactions,' 
and seven referred to in this paper, the results are as 
follows : 

Seat of sixty-tico cases of intracranial aneurism. 

/"Vertebrals 4 

Vertebrals and branches ^^^'i^''^^' ' 20 

/ Small vessel in substance of pons . i 

^Posterior cerebral .... 3 



(^Internal carotids by sella turcica 
I Middle cerebral 
Carotids and branches -{ Anterior cerebral 

I Anterior communicating . 
LPosterior communicating . 



28 



15 
6 



M 



' ' Transactions of Pathological Society,' vol. iii, p. 49. Note that in the 
table there are fifty-two cases, but No. 34 is omitted as not belonging to the 
category. 



8S DISEASES OF THE NERVOUS SYSTEM. 

Of 58 of these cases, where the sex is given, 35 were 
males, and 23 females. 

Men, it is well known, are more liable to all forms of 
aneurism than women, but there is great diiierence in the 
liability of the two sexes in respect to aneurism in different 
parts. Thus, in 137 cases of popliteal aneurism,^ 133 were 
males, and only 4 females, or 33 to i. Of 66 cases of 
aneurism of the femoral artery, 61 were males, 5 females, 
or 12 to I. The difference lessens as we come to the aorta, 
where, of 167 cases of aneurism of the thoracic aorta, 132 
were males, 35 females, or nearly 4 to i. In carotid 
aneurism the liability of the two sexes appears to be nearly 
equal, for, of 25 cases, 13 were males, 12 females. 

Fifty-eight cases, where the age is given, are distributed 
as follows : 

Under 25 years .12 

25 to 40 „ 13 

47 to 60 ,, . . . . . . -29 

Over 60 ,, 4 

58 

The relative importance of the disease at different ages is 
not, however, correctly expressed by these numbers, since in 
the later periods of life aneurism is not unfrequently found 
associated with more or less extensive disease of the cerebral 
vessels to which the symptoms and fatal results may be 
owing, the aneurism being an accidental and not important 
concomitant. In a case recorded by Dr. Bright (No. 5 in 
Dr. Brinton's table), in No. 25 of the same table, in Mr. 
Squire's case,^ and also in one given below, the aneurismal 
dilatation of the middle cerebral, as it lay in the fissure of 
Sylvius, was unimportant, and in no way concerned in the 
fatal result, which was due in all these cases to atheromatous 
disease of the vessels generally, producing softening and 
effusion of blood. It is not so, however, in younger sub- 
jects. In them aneurism commonly occurs without disease 
of the vessels generally, and is fatal either from rupture of 
the sac or from pressure or softening around it. Of 20 

^ Crisp on ' Diseases of the Blood-vessels,' pp. 134, 224, 225. 
' See Table, Case 56. 



ANEUEISM OF THE CEREBRAL VESSELS. 89 

cases occurring under thirty-five years of age, i6 were fatal 
by rupture of the sac, whilst of 37 cases over thirty-five, 
only 14 were fatal from rupture of the sac, or in other 
words, four cases out of five under thirty-five years of age 
were fatal directly from changes in the sac, but only two 
out of five over that age. 

The youngest recorded age at which aneurism within the 
cranium has been fatal is fourteen years. 

Aneurism of the intracranial artex'ies may exist as a 
general dilatation of the whole vessel for a more or less 
limited space. Mr. Hodgson^ remarks, that the internal 
carotid not unfrequently exhibits this form of dilatation of 
its entire calibre immediately it enters the skull, and he 
also refers to a case where the vertebral arteries were in 
this way enlarged into two flask-like dilatations immediately 
before their junction to form the basilar. I am indebted to 
Dr. Brinton for the notes of a similar case, which occurred 
in the Royal Infirmary in Edinburgh. The patient, aged 
thirty-eight, was admitted with paralysis of both sides of 
the body, loss of speech and hearing, and yet seemingly 
conscious. On a post-mortem examination the basilar pre- 
sented a fusiform dilatation the size of a goose-quill, which 
had produced softening of the pons to some depth. 

The aneurism may be a simple pouch of all the coats, the 
pouched portion being as transparent and normal in appear- 
ance as the rest of the vessel, giving the impression that it 
might have been some original deformity. Usually intra- 
cranial aneurism is of this form, or, as surgeons term it, 
true aneurism, the walls of the aneurism subsequently 
undergoing gradual changes, partly from continued dilata- 
tion from within, partly from chronic inflammatory changes 
in the parts around, set up by the presence of the aneurism. 
There are four conditions under which aneurism of the 
intracranial arteries may exist : the sac may be a simple 
varicose dilatation, undergoing no further change, and not 
affecting the parts around ; or it may slowly become obliter- 
ated by fibrinous coagula, and the continuity of the vessel 
be restored (such a case is recorded by Mr. Hodgson, in 
illustration of the cure of aneurism) ; or the sac may undergo 
1 Hodgson on ' Diseases of Arteries,' p. 76. 



90 DISEASES OF THE NERVOUS SYSTEM. 

slow distension, and at length rupture ; or, lastly, it may- 
act as a foreign body on the adjacent tissues, and set up 
inflammatory changes, or produce death by pressure. 

The conditions of the arterial supply to the brain are 
plainly such as reduce the pressure on the arteries which lie 
within the cranium to the lowest degree, and hence the 
tenuity of their coats. This tenuity renders them liable to 
aneurismal dilatation, from causes sometimes difficult to ap- 
preciate, but at others distinctly associated with mechanical 
injury to the cranium, or to violent muscular efforts. When 
we consider that this form of aneurism occurs in young 
persons, whose vessels are otherwise healthy, and that the 
most frequent seat of the dilatation is in those vessels which 
lie in contact with the bones at the base of the cranium, 
there is yet further probability that mechanical causes, 
acting locally, have much to do with the origin of disease. 

There do not appear to be in the nature of the case any 
symptoms, or order of symptoms, upon which a diagnosis of 
cerebral aneurism can be made. The liability of the cere- 
bral vessels to this lesion must, however, always enter into 
our calculations in the general diagnosis of tumours, especi- 
ally when there is evidence of local pressure on parts about 
the base of the brain. From the frequency of basilar 
aneurism this would be most frequent on the pons Varolii, 
since there the conditions for pressure are most favourable. 
Symptoms may therefore, in such a case, begin from the 
earliest period of the formation of the aneurism, and con- 
tinue for years before a fatal termination. It was so in 
Pfeufer's^ case, where, according to the patient's account, he 
had for some years been subject to attacks of sudden inability 
to swallow. There was no regularity in the attacks, but 
they seem to be induced by swallowing food hurriedly, or 
by exposing- the neck to cold, symptoms which indicated 
disturbance of the medulla oblongata, as it was afterwards 
proved, from the formation of an aneurism on the basilar 
artery. Subsequently he had headache, general convulsive 
attacks (ushered in by the convulsive affection of the throat), 
and paraplegic weakness of the lower extremities. In 
1 ' Zeitschrift fiir Rationelle Medizin,' Erst Band, s. 293. (Case 9 in 
Synopsis.) 



ANEURISM OP THE CEREBRAL VESSELS. 91 

another case^ sudden and absolute deafness was the earliest 
symptom of basilar aneurism, as long as four or five years 
before its fatal termination of rupture. The only patho- 
logical condition found was atrophy of each auditory nerve, 
which Dr. Van der Byl, who reports the case, thinks might 
have been produced by obstruction of the small branches of 
the basilar supplying the auditory nerves. The suggestion 
is important, as indicating how an aneurism may affect 
adjacent parts otherwise than by pressure. Deafness, as an 
early symptom of basilar aneurism, has been noticed in 
several other cases, and may have arisen from the cause 
here supposed, since the anatomical conditions about the 
sac itself did not seem sufficient to explain it. In contrast 
with these cases, which show how early the parts adjacent to 
an aneurism of the basilar may suffer, there are others where 
the sac has attained a much larger size without any sym- 
ptoms to indicate its presence. Dr. Corfe, in his notes on 
the physiognomy of diseases^ (Table, Case 3), relates the 
case of a man, abaut forty years of age, who was brought 
into the Middlesex Hospital in a state of insensibility into 
which he had fallen just before. The man had been working 
up to the time of the attack, and was apparently in the en- 
joyment of tolerable health. He died a few hours after 
admittance, and on a post-mortem examination there was 
found an aneurism of the basilar artery as large as an ordi- 
nary walnut, which covered the pons Varolii and a portion 
of the medulla oblongata. The same state of things occurred 
in a boy aged fourteen ; and aneurism of the basilar as large 
as a walnut existed, without symptoms, until the system was 
disturbed by another cause of febrile excitement (Table, 
Case 4). The following table of cases of aneurism of the 
basilar artery exhibits a synopsis of the clinical history of 
the disease, and subsequently there is added a similar ar- 
rangement of clinical history of aneurism at other seats, 
from all which it will be confirmed that, although we may 
from the circumstances sometimes suspect the presence of 
aneurism within the cranium, we have, at the best, no sym- 
ptoms upon which to ground more than a probable diagnosis. 

' 'Pathological Transactions,' vol. vii, p. 123. 

^ 'Medical Times,' vol. xvi, p. 591. 



92 



DISEASES OP THE NERVOUS SYSTEM. 



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ANEURISM OP THK CEREBRAL VESSELS. 95 

The symptoms of aneurism of the basilar artery, though 
not diagnostic of the nature of the particular lesion, form, 
upon the whole, a natural group indicating its presence and 
its seat. It is not so, however, where the middle cerebral 
artery is aifected, for it Avill be seen that in such cases there 
was often no clinical history previous to the rupture of the 
sac ; or, if any, none to indicate unequivocally the presence of 
organic lesion. Exceptions to this there are when the sac 
has become large, so as to compress the central parts about 
the base, as in the Case 4 below. Where the arteries of the 
circle of Willis are the seat of the aneurism, there may also 
be the same vagueness in the indications of organic disease ; 
but in two cases where the posterior communicating artery 
was affected, ptosis, from compression of the third nerve, was 
an early symptom. 

As with other tumours so with intracranial aneurism, 
headache, though difficult to estimate strictly, is one of the 
most important symptoms. The one character of it which 
should most arrest our attention is its constant recurrence 
and its often distressing severity, with concomitant disturb- 
ance of the cerebral functions. All care, however, will often 
fail to enable us to foi'm a correct opinion ; even should we, 
as some have suggested, auscultate the cranium for an 
aneurismal murmur! 

Intracranial aneurism often serves to illustrate to us how 
much the whole nutrition of the brain may be affected by the 
operation of a strictly local lesion. It may lead to subarach- 
noid and ventricular effusion, and produce symptoms of in- 
sanity and epilepsy. In this the brain differs from the solid 
viscera of the abdomen. This is probably attributable to 
the quality of the normal action, the morbid condition being, 
in popular language, attributable to a disturbance of the 
nervous polarity. But whatever the explanation, this fact 
in the clinical history of cerebral lesions explains how 
various may be the phases of cases which, in their general 
anatomical details, may be alike, the degree to which this 
altered molecular change occurs varying, probably, accord- 
ing to the original quality of the nervous substance in 
different individuals. 



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ANEURISM OF THE CEREBRAL VESSELS. 99 

Case i. — After more or less continued headache for six months, a convul- 
sion in sleep, folloived by cerebral oppression and deafness ; slotvness 
and feebleness of all the voluntary movements, ivithout distinct para- 
lysis ; about three weehs after seizure sudden coma and death in 
three days ; aneurism of the basilar artery ; superficial softening of 
pons Varolii; effusion of blood from rupture of the sac. 

Hugh B — , ajt. 34, a large, tall, heavy-looking man, with a syphilitic 
blotch on the upper lip, was admitted under my care into Guy's Hospital, 
December 24th, 1855. In 1853 ^^ l^ad a severe blow on the back of the 
heac when drunk, and was laid up for a fortnight. After this he fre- 
quently vomited in the morning, which was at the time attiibuted to his 
drunken habits. In the summer of 1855 he began to complain of head- 
ache, but continued working in his usual health until a fortnight before his 
admission into the hospital. At this time he had a convulsion in his sleep, 
and remained insensible for three days. On recovering his consciousness, 
the mind was dull and the memory very defective. When first visited, the 
following note was made of his condition : — " He has an anxious oppressed 
look. After repeated questioning to bring him to the subject, he gives a 
generally correct account of himself, but his memory is obviously defective. 
He has pain at the back of the head and down the neck, and cannot bend 
the head forward with freedom. Pressure over the transverse processes on 
the right side of the neck, and deep down to the occipital condyle, makes 
him complain. When asked if he has headache, he says, slowly and with 
indifference, ' Yes, occasionally.' He often puts his hand to his head and 
exclaims, ' Oh, dear.' There is a marked degree of deafness on the right 
side, which dates from the seizure. There is no paralysis of the extremities, 
or of the muscles of expression, but all the voluntary movements are pei'- 
formed slowly and feebly. Urine and faeces sometimes passed involuntarily. 
No difficulty in deglutition. No vomiting or nausea. Pupils rather large 
and sluggish ; the left oval, and somewhat larger than the right. Sight 
unaffected. Pulse 60. Rhythm regular. Respiration 20, with occasional 
slight and Ineffectual cough, as if restrained by fear of shaking the head- 
He was emaciated considerably since the seizure. Abdomen sunken. Con- 
stipation. Urine abundant, without deposits ; not albuminous. Surface 
cool. Extremities cold. Mouth affected by mercury." After this report 
there was no important change in his symptoms until January 4th. His 
appetite was rather voracious. He continued to complain of pain in the 
back of the head and in the neck when he was moved. The whole muscular 
system became much enfeebled, but without distinct paralysis of any part. 
Early in the morning of the 4th he was found comatose, with dilated 
pupils, eyes in constant oscillating movement, and slight convergent 
strabismus. Urine and faeces passed under him. Face inexpressive. 
Breathing stertorous. Pulse 76. Respirations 17. Conjunctivae injected ; 
the right covered with muco-purulent secretion. On the 5th his state was 
the same. On the 6th the skin was very hot and sweating. Respirations 
40, stertorous. Pulse 160. Death early on the morning of the 7th, one- 
month from the first seizui'e. 



100 DISEASES OF THE NERVOUS SYSTEM. 

Post-mortem examination. — Effusion of clear fluid into ventricles. At 
the anterior part of the basilar artery there was an aneurism the size of a 
small nut. The sac contained a firm clot. Around it, into the subarachnoid 
space there was recently effused blood. Fibrinous coagulum, continuous 
with that in the sac, extended into the trunk of the artery in both directions. 
The superior cerebellar and the posterior cerebral arteries were pervious. 
The posterior communicating arteries were filled with recent coagulum. 
The substance of the pons beneath the aneurism seemed to the eye quite 
uninjured, but a microscopical examination detected numerous " granule- 
masses " in the superficial j)arts. The blood-vessels in all the other parts of 
the brain wei'e healthy. The effusion of blood around the sac was evi- 
dently as recent as the last seizure, three days before death. The cervical 
spine was carefully examined ; the cord, nerves, and all the other textures 
were healthy. The thoracic and abdominal viscera were healthy. 

In this case and in Case 6 there was a distinct history of 
injury^ and in both the arteries in the other parts beyond 
the aneurism were perfectly healthy. The symptoms were 
plainly indicative of disease at the base of the brain, and a 
consideration of the whole clinical history of basilar aneu- 
rism should in a similar case suggest the probable nature of 
the lesion. The inflammatory changes around the sac were 
slowly bringing matters to a fatal issue, apai't from rupture 
of it j but as they advanced the sac received less support from 
the softened nerve-substance, and hsemorrhage kindly cut 
the thread of life. 

■Case 2. — Aneurism in the substance of the pons Varolii ; ingravescent 
apoplexij ; death in three hours and a half. 

Mrs. W — , fet. 43, wife of a publican, complained for about a fortnight 
before her death of dyspepsia, flatulence, and headache, which she described 
as at times "quite overpowering." At 7 p.m., February 26th, 1S58, she 
was assisting at the bar, when suddenly she cried out, " Oh, my head — I'm 
dying ! " and fell backwards. She never spoke afterwards, but was partially 
conscious for two hours, being able to open her mouth when told to do so, 
and to move the left leg and arm. When visited at half past 9 p.m., she 
was perfectly comatose ; lay supine, with the limbs extended and flaccid. 
The jaw fallen. The pupils minvitely contracted and immoveable. Breathing 
greatly emban-assed from paralysis of the larynx. Respirations 36, sterto- 
rous, and with an expiratory moan. Walls of chest scarcely moving during 
inspiration, the larynx at the same time descending, and the supra-clavicular 
spaces being depressed ; now and then a fuller sighing inspiration. Pulse 
varying from 70 to 90 in the minute ; irregular in force and rhythm. 
Carotids throbbing. Face pale. Muscles of deglutition and tongue quite 
paralysed. Occasional ineffectual efforts to vomit, with the expulsion of a 



ANEURISM OF THE CEREBRAL VESSELS. 101 

little mucus. There had heen no Involuntary evacuation o£ the rectum or 
bladder. Urine drawn ofE by the catheter pale, and containing a small 
quantity of albumen. Death the same evening, three hours and a half from 
the seizure. 

Post-morte')n examination. — Arcus senilis well marked. A large quantity 
of subcutaneous fat on the abdomen. Heart normal in size and structure. 
Kidneys under the average size ; their surface granular, and tunics adherent. 
Arachnoid of the surface of the brain granular and opalescent, with several 
drachms of clear fluid in the meshes of the pia mater. Lateral ventricles 
healthy. In the lower third of the pons Varolii, in the middle line, a recent 
coagulum weighing two drachms. On removing this a pyriform aneurism, 
having much the appearance and size of a withered grain of wheat, was 
seen projecting from the floor of the cavity produced by the efEusion of 
blood. The blood had escaped from a longitudinal slit in the sac. The 
brain-substance around the coagulum presented no evidence of softening 
preceding the efEusion of blood. The basilar artery was mottled throughout 
by opaque fatty deposits. 

The seat and minute size of the aneurism in this case are 
the chief points of interest in it. It presents in other parti- 
culars the ordinary history of apoplexy of the pons Varolii. 
It is a question raised by this case how far atheromatous 
changes in the larger arteries may throw the ventricular 
impulse upon the smaller vessels of the brain, and lead to 
aneurismal dilatation of them. The flatulence and dyspepsia 
which for a fortnight preceded the apoplectic seizure may 
have been premonitory of it. The more decided disturb- 
ance of the stomach in nausea and vomiting is notoriously 
often referable to the brain, and there is reason to believe 
that the pneumogastric nerves are frequently the channels 
through which early symptoms of impending apoplexy ex- 
hibit themselves. 

Case :i.— Severe headache, continuing three days, followed by hemiplegia 

and coma ; gradual exhaustion ; sudden exacerbation of symptoms a 

few minutes before death, eight iveehs from onset of symptoms; aneurism 

of left middle cerebral artery in the anterior part of left middle lobe 

of cerebrum; softening around the sac; laceration of corpus striatum 

and thalamus opticus by large effusion of blood from bursting of the 

sac ; lateral ventricles full of blood. 

Louisa B— , ajt. 17, a fair, delicate girl, employed as a domestic servant, 

enjoyed good health until two months before her death. About this period 

she became the subject of rheumatism from exposure to cold and damp. 

Her rheumatic symptoms amounted only to slight swelling of the right 

knee, and wandering pains in the limbs ; she was still able to continue her 




102 DISEASES OF THE NERVOUS SYSTEM. 

work. January 1st, 1858, she complained of headache, which was unusually 
severe on the 3vd, and in the afternoon of that day, whilst talking to a 
friend, she suddenly lost the power of speech, and became paralysed on the 
right side. There was no reliable account of her condition from this date 
until the loth, when she was admitted into Guy's Hospital, under the care 
of my colleague, Dr, Owen Rees. Her skin was then hot and dry. She lay 
comatose, with the right side paralysed. Pupils dilated. Urine and faeces 
passed unconsciously. Bedsore over sacrum. Heart's action sharp. Pulse 
1 10. Dui-ing ten days after her admission there was no important change 
except increased exhaustion. She frequently moved the left hand to her 
head, as if in pain. On the 25th the pulse was not perceptible at the wrist. 
On the 26th, at half -past II a.m., she suddenly gave a scream, and the face 
became congested. Death after a few minutes, without convulsions. 

Post-mortem examination. — In the substance of the middle lobe of the 
cerebrum on the left side, and on the principal division of the middle 
meningeal artery, there was an aneurism of 
the size of a small nut, surrounded by a large 
recent coagulum and softened brain-tissue. 
Part of the coagulum consisted of fibrin which 
had separated from the effused blood, as in the 
formation of the huffy coat. The anterior 
third of the corpus striatum and the principal 
part of the thalamus opticus was broken up 
by the effusion, which had also filled the lateral ventricles and suiToimded 
the crura cerebri and medulla oblongata. The arteries were healthy ; weight 
of heart nine ounces. Valves healthy, with the exception of some granula- 
tions on the mitral. Spleen large, full of blood, and containing several 
white fibrinous masses ; a section of one of the largest of these presented 
numerous points of softening. Kidneys large, with similar fibrinous 
masses (embolic), with blood effused around them. The outer coat of the 
aneurism consisted of a very thin layer of areolar tissue, the thicker part of 
the sac of laminated toughish fibrin. 

RemarTis. — The previous occurrence of rheumatism, with 
signs of endocarditis, led at first to the opinion that the 
hemiplegia might be owing to emboli obstructing one of the 
cerebral vessels. This was apparently confirmed at the post- 
mortem examination by the fibrinous exudations in the liver 
and spleen, and it was only after careful search that the 
aneurismal sac was discovered in the midst of the softened 
tissue and clot. The effusion of blood had evidently taken 
place at the time of the last and fatal seizure. There was 
no trace of any old coagulum, so that we must refer the 
sudden hemiplegia to ramollissement only, around the sac. 
These changes were gradually inducing exhaustion when, as 



ANEURISM OF THE CEKEBRAL VESSELS. 103 

usual, the sac ruptured and cut short the case by profuse 
hEemorrhage, What determined the presence and seat of 
the aneurism could not be conjectured. The arteries else- 
where were entirely free from disease, and so was the trunk 
of the vessel in which the aneurism was seated. 

Case 4. — Ingravescent wpoiilexxj from rupture of an aneurism on middle 
cerebral artery of left side ; death on the sixth day. 

Fanny S — , set. 30, of middle stature, dark complexion, of rather ema- 
ciated and cachectic aspect, was admitted into Guy's Hospital on the 5th of 
November, 1850. The account given was, that she was cook in a family, 
and the previoiis evening had left home in perfect health, accompanied by 
a female friend. Whilst walking she suddenly called out, "' Oh, my head ! " 
and put up her left hand. She vomited, and, as her friend thought, fainted. 
After a brief interval she partially recovered, and was able to walk back to 
her residence with the support of two men. By the time she reached home 
she had recovered her consciousness sufficiently to ask her friend to conceal 
tlie fact of her having left the house. She took some tea and walked 
upstairs to bed, and was left, as it was supposed, asleep, but in reality in a 
state of gradually increasing coma. When admitted into the hospital at 
noon the following day only a slight impression could be made by any 
attempt to rouse her. The right arm was quite paralysed, the muscles 
flaccid; the right leg in the same condition, with only slight traces of 
excito-motor action when the sole of the foot was tickled. Features inex- 
pressive. Both pupils contracted. Eespirations 32, tranquil. Pulse 70. 
Heart's action sharp, without any abnormal murmur. Urine drawn off by 
the catheter free from albumen. In the evening the left pupil had dilated, 
and was immovable on the stimulus of light ; the right remained contracted. 
The left eyelid was slightly fallen. The patient turned herself over in bed 
in a restless manner, and frequently put the left hand to her head. Face 
flushed and inexpressive. Eespirations 24. Pulse 60. November 6th, the 
breathing stertorous. Pupils variable, at one time contracted, at another 
dilated, without any external cause. Deglutition difficult ; urine and fajces 
passed unconsciously. On the 8th she appeared more sensible, ate some 
bread and butter, and when spoken to made an attempt to answer, but was 
unable to articulate. The head was rolled from side to side, and the left 
hand lifted to it, as if in pain. On the 9th the catamenia appeared rather 
profusely, and she so far rallied as to recognise a relative who visited her, 
and to say distinctly, " My cousin." On the evening of the loth her sym- 
ptoms became aggravated, the face flushed, the eyes suffused, pupils dilated 
and fixed. Eespirations 26, with an occasional prolonged expiratory effort. 
Pulse 72. Twitching of left side of face. Death a few minutes after this 
report. 

Post-mortem examination. — On removing the membranes of the bram 
the anterior convolutions of both hemispheres were evidently flattened. 




104 DISEASES OF THE NEEVOUS SYSTEM. 

Under the arachnoid, on the left side, there was extravasation of hlood, 
filling the sulci between the convolutions and blocking up the fissure of 
Sylvius. On making a section through the centrum ovale majus, the sub- 
stance of the left hemisphere, external to the 
corpus striatum and thalamus opticus, was found 
softened to a great extent, and in the midst of this 
softened portion recent coagula and bloody serum. 
The effusion had not extended into the ventricles. 
The middle cerebral artery, on the left side, had 
upon it two small aneurisms. One of these had 
ruptured by a circular opening and given rise to 
the hajmorrhage. The descending comu of the 
left lateral ventricle contained bloody serum, and 
the tissue was softened in many spots. Heart small, covered with fat ; 
muscles soft and greasy. Some thickening of the mitral valve. Kidneys 
and other viscera healthy. 

Remarks. — The length of time from the rupture of the sac 
to the fatal termination was explained by the state of parts 
after death, for the haemorrhage, though extensive, had not 
broken in upon the central parts, but was spread out under 
the arachnoid. The remission of the symptoms on the fifth 
and sixth days was remarkable, and may have been due to 
changes in the clot, the pressure on the surrounding parts 
becoming equalised by its contraction and by absorption of 
the serum which had diffused itself through the softened 
tissue. 

Case ^.—Ingravescent apoplexy ; convulsions ; atheroma of cerebral 
vessels ; very large effusion of hlood into right hemisphere ; aneurism 
of middle cerebral artery on left side as it lay in the fissure of 
Sylvius. 

Mr. P — , set. 58, of intemperate habits, and recently the subject of deli- 
rium tremens, whilst reading on Sunday evening, February 28th, 1859, 
dropped his book from the left hand, and his speech became indistinct. 
There was no exclamation. After an hour a violent convulsion came on, 
affecting the right side only. Convulsions returned four times at the interval 
of an hour or so, always limited to the right side, the left being slightly 
flexed and rigid. When the convulsions ceased he was able to answer ques- 
tions, though slowly and indistinctly, and pointed to the right temple as the 
seat of pain. When visited five hours from the commencement of the 
seizure he was lying supine in a state of semi-coma, from which he could be 
partially roused ; breathing stertorous ; pupils contracted, only slightly acted 
on by light ; optic axes divergent. Pulse 112. The following day, at one 
o'clock, he lay in the same state, and still pointed with his right hand to his 



ANEURISM OF THE CEEEBRAL VESSELS. 105 

forehead when asked if he had pain, and even muttered a few words indis- 
tinctly. The left side rather rigid and motionless. Priapism. In the 
evening the breathing became slower, and the coma more profound. lie 
died forty -four hours from the beginning of the attack. 

Post-viortem examination. — In the right hemisphere, external to tlie 
corpus striatum and thalamus opticus, and not breaking through either to 
the surface or into the ventricle, was a large effusion of blood, which had 
formed a cavity four inches in its antero-posterior extent, two inches and a 
half transversely, and one inch and three quarters vertically. The cerebral 
vessels were extensively atheromatous. In the fissure of Sylvius, on the 
left side, the middle cerebral artery was dilated into an aneurismal pouch 
the size of a large pea. The coats of the vessel forming the sac were trans- 
parent, nor was there any trace of lesion in the textures around. Its 
presence was a mere coincidence, and from all appearance it may have 
existed as an original deformity. 

Case 6. — Headache at intervals for five years, sometimes severe ; vertigo ; 
tinnitus ; sudden convulsive seizure, rapidly jyassing into coma ; death 
in eight hours. Aneurism on anterior cerebral artery ; rupture of 
sac ; large effusion of blood over surface of brain and into the ven- 
tricles. 

Mrs. V — , set. 35, of a delicate, rather spare, and ansemic habit, had for 
five years been troubled at times with headache, vertigo, indistinctness of 
sight, a sense of thickness in the ears, with tinnitus, and occasionally a 
noticeable slowness in apprehending what was said to her, though the intellect 
was clear. There was no such distinctness in her symptoms, however, as to 
lead to the suspicion of any organic disease in the cranium. Her ailments 
seemed to be referable to more general conditions, associated with slight 
anaemia and constipation. About eighteen months before her death she liad 
an attack of headache, which continued for a fortnight, and prevented her 
leaving her room. The pain was never referred to any given spot, nor to 
the right or left temple ; more commonly, in describing it, she put her hand 
to the occiput. Catamenia normal. My friend Mr. John Burton, of Black- 
heath, whose patient this lady was for a few months preceding the fatal 
seizure, informed me that her principal symptoms were vertigo, stuffing and 
ringing in the ears, a sense of general weakness, and constipation, and that 
she was apparently relieved by the use of iron and aloes, and by syringing 
the ears. The day before the fatal attack she was in her garden planting 
seeds, and was more cheerful than usual. At noon the next day she was 
taken with vomiting, and soon after fell into convulsions. At 2 p.m. the 
convulsions had ceased. She lay in profound coma, with the right arm 
flexed and rigid, and the right pupil dilated ; the left side was flaccid and 
motionless, the left pupil contracted. Towards death both pupils became 
dilated and the trunk universally paralysed. Death at 9 p.m., eight hours 
from the beginning of the attack. It only subsequently transpired that 
this lady had had a fall from her horse a few weeks before her symptoms 
tegan. 



106 DISEASES OF THE NEEVOUS SYSTEM. 

Post-mortem examination. — The brain, both on the surface and in the ven- 
tricles, was inundated with blood, which had escaped from a rent in an aneu- 
rism of the anterior cerebral artery of the left side. The aneurism extended 
over to the right side, lying over the optic nerves. The sac at its distal part, 
on the right side, was formed by coagulated fibrin, and by the under surface 
of the inner angle of the anterior lobe of the cerebrum. The rupture had so 
occurred as to lacerate that portion of the brain which formed the floor of 
the third ventricle. The ventricles were full of blood, and the subarachnoid 
tissue infiltrated over the whole surface, but principally about the base and 
between the hemispheres. The brain-substance was nowhere destroyed but 
at the part indicated. The cerebral vessels were generally healthy. No 
spots of atheroma. The principal part of the sac of the aneurism was trans- 
parent, and formed of the normal coats of the vessel distended, but at its 
distal part, under the right hemisphere, the coats had given way, and the 
sac was formed, as described above, of a thin layer of fibrin and of the 
brain-tissue adjacent. The direction of the aneurismal dilatation was 
upwards and to the right side, in the course of the arterial current, and thus 
the optic nerves escaped pressure. The line of rupture also lay in the direc- 
tion of the arterial current — namely, forwards and upwards, the effused 
blood tearing the floor of the third ventricle, and distending the meshes of 
the pia mater. The aneurism had been evidently for a long period of 
its existence what is called a true aneurism. 

Remarks. — There vs^as one symptom in this case which 
indicated more than others some organic disease about the 
brain — the occasional noticeable slowness in apprehending 
what was said. Slight as it seems to have been, it was in 
its character of the highest importance. In what way a 
local cause like aneurism should so affect the whole cerebrum 
is not to be explained until we know more of the nerve- 
force ; but, as remarked above, we may suppose a local 
lesion capable of altering the polarity of the adjacent nerve- 
tissue and the condition of the rest. 



DISEASES OP THE NERVOUS 
SYSTEM. 



(b) DISEASES OF THE SPINAL COED. 



THE GULSTONIAN LECTURES/ 

DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANS, 

1848. 



LECTURE I. 

ON THE NERVOUS SYSTEM. 



Mr. President, — In appearing before the College to fulfil 
the duty which has devolved upon me by your appointment 
I cannot but express the sense I have of the houour con- 
ferred upon me, and my regret at the small means at my 
disposal for the due performance of the task. My previous 
engagements have left me but little leisure for new investi- 
gations. I am, therefore, afraid I can bring before you 
little that is new. I have chosen out some points in the 
physiology of the nervous system, particularly in reference 
to an arrangement of paralytic and anesthetic affections. 
In this first lecture it will be my endeavour to set forth the 
present state of our knowledge in regard to physiology only ; 
in the next lecture to consider some facts relating to para- 
plegia ; and, in the third lecture, the phenomena and law of 
hemiplegia, with the exceptions. Of the importance of the 
nervous system we may form a just estimate when we re- 
member, that in the development of the embryo of the 
higher animals, it is the first which appears. (The lecturer 
illustrated this by referring to a diagram of the embryo of 
the dog.) The first traces of the vertebrate form are in 
these simple lines of nervous substance ; this is the centre 
in relation to which all the parts of the future animal are to 

^ Reprinted from the 'Medical Times and Gazette,' 1848-9, vol. xix, 
p. 371, etseq. 



110 ON THE NERVOUS SYSTEM. 

be laid down. The nervous system has this priority, not 
only in foetal development, but manifests it throughout the 
whole life of the individual. On reviewing the phenomena 
presented to us by the higher animals, we are led to the 
conclusion that their vertebrate organisation is an adaptation 
especially for action, being a co-ordinated system of nervous 
centres, nerves, muscles, and bones. The digestive system, 
corresponding to the mucous layer as the nervous does to the 
serous, is necessary for receiving the nutriment from without, 
and for elaborating it into the constituents of the blood, 
whilst the intermediate system of blood-vessels conveys the 
renovating and nutrient fluids to the first great system, and 
removes the worn-out tissues ; but these two systems, the 
digestive and the vascular, are subordinate in the idea of the 
vertebrate type. 

In each segment of this great system we find several 
elements, each of which has its own function ; although so 
great is the unity of the whole that no part can suffer with- 
out affecting the rest. 

The muscle represents many units of power, according to 
the number of its fibres, many muscular fibres being sub- 
mitted to the influence of one nerve-fibre, and many nervous 
trunks inserted into one common centre — gradual concen- 
tration and subordination for the purposes of arrangement. 

The muscle has its own inherent and proper power of con- 
traction in virtue of its organisation, and nerve is the proper 
exciter of this power, in a manner not explained ; all we yet 
know being this, that a nerve, when mechanically disturbed, 
or affected with an infinitesimal amount of electricity, brings 
out the function of the muscle. We can compare the 
phenomena to nothing so aptly as to a spring set free by the 
easy motion of its stop. On irritating the nervous centre 
we no longer obtain the same simple results, but the pheno- 
mena give us the idea of system, not merely sum of units, 

but UNITY OP PLAN. 

The function of each part is obviously distinct ; yet, in the 
higher animals especially, there is a most intimate combina- 
tion and dependence, from muscle to nerve and from nerve 
to centre. 

The advances of anatomy have demonstrated this in 



ON THE NERVOUS SYSTEM. Ill 

respect of tlie three elements. It is more than conjecture, at 
least in many instances, that the grey caudate cells of the 
nervous centres are continuous ^vith the nerve-fibres, and the 
ganglionic masses on the posterior roots of the sensitive 
nerves in the lowest Vertebrata, where the tissues were so 
loose as to permit a successful inquiry, have been shown to 
arise from a vesicular dilatation of the nerve-tubules in their 
course. 

Of the mode of termination of the nerves in the muscles 
and skin, facts of the greatest interest seem to have been 
fully ascertained. In respect of muscle the pinmitive nerve- 
tubulus, after reaching its surface, has been found to divide 
into two, or often many branches, instead of forming loops 
with fibres returning into the trunks from which they were 
sent off, as described by Breschef. There is yet, however, 
uncertainty as to the precise manner in which these branch- 
ings of the nerve-fibre end in the muscle ; yet is there much 
probability of direct continuity. 

In respect of the skin and the cellular parenchyma of 
organs, there is at least a very close intermingling of nerve 
and fibre-tissue, if not absolute continuity of structure ; so 
that it might not be too bold an expression, however 
illogical, to say that they formed an extended peripheral 
centre. 

Passing onwards from these established truths, we come 
to consider the central parts of the nervous system ; and the 
first question for our consideration is their symmetry. Is 
there one general centre, or are there many, — and if many, 
what is their arrangement and mutual relation ? The second 
question is, — Does the same law hold good in regard to 
centres as to nerves ; namely, is there one collection of grey 
matter for sensation and another for motion ? 

In reference to the number of centres and their arrange- 
ment, the most striking theory is that proposed by Dr. Hall ; 
namely, that there is a true spinal system, made up of 
many segments, and a distinct sensory and volitional one. 

That the spinal cord is more than a collection of nerves 
running to or from the brain has long been maintained. 
The movements of decapitated animals have led to many 
speculations ; some of the older physiologists regarding 



112 ON THE NERVOUS SYSTEM. 

them as the result of a residual irritability of the muscles, 
others thinking they arose from nervous sympathy ; and 
Prochaska and Le Gallois, with others, regarded them as the 
result of a reaction on the spinal cord, in which the latter, 
at least, admitted sensation to exist. Dr. Hall has more 
fully than anyone else investig-ated these movements, and 
explains them, and a series of others in our own bodies, 
by referring them to a simple physical reaction, from 
which sensation is excluded as a necessary part, though 
often conjoined ; whilst other movements, the results of 
Volition and sensation, are carried on by quite a distinct 
system. However suitable such a supposition of two dis- 
tinct sets of nerves might be to explain many phenomena 
■of nervous action, yet are there many great objections to 
the hypothesis. In the first place, they must be equally 
extensively distributed in the skin and muscles. For as, in 
a decapitated animal, there is no part of the surface which 
cannot excite the spinal system, so is there no part, when 
the animal is entire, which, when injured, does not give rise 
to sensation. Again, the movements of the muscles are 
performed after the same manner, whether the muscles are 
acted upon by volition or by a physical reaction of the cord 
only. Hence we cannot but infer that the relation of the 
exciter and of the volitional fibres to the muscular tissues 
are the same. For instance, in a decapitated frog the legs 
are drawn up when pinched ; so are they when the animal 
uses them under volition. The extension of these two 
systems, therefore, must be equal, and their arrangement 
similar ; but to what purpose is not evident, inasmuch as we 
shall see afterwards that one set of fibres only, viz. the 
spinal set, would suffice. Another objection, which has 
seemed to me pressing against the theory of a volitional and 
an excito-motor set of fibres, arises from the power we have 
over these automatic movements. Take, for instance, the 
respiratory movements : we can arrest them at will ; and in 
this we find a dilemma, — for, if we assume that the volition 
acts directly upon the muscles, the influence so sent to them 
can he no other than a stimulus ; and if we cut off the 
stimulus of volition by a negation, we leave the muscles 
acted upon by the reflected irritation from the cord, which 



ON THE NERVOUS SYSTEM. 113 

is powerful enough to excite them : hence they would con- 
tinue to contract, and the volition would be powerless to 
stop them. But, if it be admitted, that the centre of voli- 
tion can act directly upon the spinal centres, arresting the 
course of the impression from the incident to the motor 
nerves, then we can readily understand the manner in which 
we arrest the movements ; but then the volitional fibres 
running from the brain to the muscles are unnecessary j for, 
if we can excite the muscles by acting dii"ectly upon the 
centres of the spinal cord with which they are connected, 
there can be no necessity for a double set. 

Dr. Todd has well set forth, in his various writings, our 
ignorance of the exact arrangement of the nerves in the 
cord, the improbability of the longitudinal fibres being 
continuous with the nerves ; and, after a careful repetition 
of the dissections of Mr. Grainger, arrives at the conclusion, 
that considerably the greatest number of fibres pass in at 
right angles (to the segments of the cord), whilst those 
which might be supposed to take an upward course axe few 
and indistinct. The results of all this investigation being, 
that there is no satisfactory evidence of the cerebral fibres. 

I have quoted the remarks of this excellent observer first, 
because his name is a great authority for their correctness ; 
but will now add other evidence, which has been brought 
forward, and which tends to confirm this view. 

As regards the tracing of fibres, a great source of fallacy 
arises from the softness of the tissue of the nervous centres, 
and from the lateral adhesion of the fibres themselves, so 
that with these difficulties before us, nothing less than an 
actual tracing of primitive fibres by the aid of the microscope 
could be certain evidence ; and this has never been done to 
any appreciable extent. We must, therefore, form our 
conclusions as to the general arrangement of the nervous 
structures from more obvious conditions. 

Yolkman adduces, as a proof that all the nerves do not 
arise in the brain, the instance of the crotalus mutus, in 
which he numbered 221 pairs of spinal nerves. He pro- 
ceeded to a careful measurement of their united area, and 
found that it surpassed by eleven times the area of the cord 
at its superior part. Sir C. Bell admitted that the respira- 



114 ON THE NERVOUS SYSTEM. 

tory nerves arose from the cord^ and we have in the musculus 
accessorius what Bacon would have styled a glaring instance 
of spinal origin ; for we can give no account of the strange 
course it must take, if it has a cerebral one. 

If we select any animal remarkable for the muscular 
power of any segment of its skeleton, we shall find, as has 
been commonly stated, a corresponding development of the 
cord ; and, as two such examples, I show you the cord of 
the jerboa and turtle. The same exists in the cetaceans 
which use their tail as the chief propelling organ, although 
some, speaking from theory rather than observation, have 
said that it is absent when the members are absent. As 
further tending to illustrate the arrangement of the nervous 
centres, we may refer to the present prevailing views of the 
symmetry of the vertebrate skeleton. 

If it be proved that the skeleton is developed according 
to a definite plan of longitudinal repetition of simple 
elements, every segment or group of segments being modi- 
fied in relation to the whole, whereof the proof is given in 
the harder parts of the animal structure, and the law and 
idea of the archetype traced out therein, on a due considera- 
tion of these facts, it must seem obvious that what holds of 
them will hold of the nervous centres, of which they are the 
mere supports. So that if we may recognise in a vertebra 
of the back a unit of the whole skeleton, limited or extended 
in the development of its parts, according to particular 
wants of the whole animal, we may, a fortiori, admit the 
spinal segment of the cord corresponding thereto, to form a 
unit in the nervous mass ; and the same segmental or zonal 
symmetry which has, in modern times, been so successfully 
made evident in regard to the bony frame- work, must be 
admitted to obtain in the nervous centres, in relation and 
subordination to which all other parts are formed. 

If we, therefore, reason from the known to the unknown, 
we shall be prepared to find in the nervous system the same 
kind of relations as in the vertebrate skeleton itself, — the 
same in kind, I say, but with a closer correlation than is 
even there apparent. There can be no more objection, 
a priori, to a mechanical arrangement of the nervous and 
muscular systems adapted for motion than to an optical 



ON THE NERVOUS SYSTEM. 115 

apparatus for concentrating and absorbing the rays of light 
in seeing. This would, in fact, constitute the true spinal 
system of Hall ; and, as Dr. Todd remarks, we must regard 
the decussating fibres of the anterior pyramids as com- 
missural only. 

We have, in the spinal cord, with its nerves and their 
conjoined muscles, a mechanism which, under ordinary 
conditions, is submitted to our volition, as in the segments 
corresponding to the arm and leg, or which can act auto- 
matically and yet be subject to volition, as the segments 
ministering to respiration, or which are mechanical only, as 
deglutition. And when we consider in detail the degree 
and kind of power we have over our muscular system, these 
views seem to me greatly confirmed. As for example, I 
may revert to the volitional power over respiration. How 
do we produce this complex movement ? Not by our voli- 
tion having any power to select out one or two individual 
muscles, nor even the muscles of one side, — but we produce 
the result as a whole. Nor is there any necessity for all 
these fibres to run to the brain, seeing that when they 
arrive there, as our common experience tell us, we have no 
power of selection over them, and particularly as one excitor 
fibre, or other equally simple means, from the brain would 
suffice, as proved by the simple fact, that such an irritated 
fibre does suffice to set the whole respiratory system into 
consentaneous action, as in sneezing, which may be set up 
by an impression conveyed through one fibre. But if this 
example be objected to we may instance those parts of the 
body which are most obviously under the influence of the 
will, say the arm or leg ; the same inability of directing our 
volition upon any one muscle obtains also here. We will a 
particular movement, for example, flexion or extension of 
the arm, or adduction of the thigh, and we get the result 
without any obvious combination of elements. How 
numerous soever the muscular fibres of any one muscle, or 
of the muscles themselves, for a given result, we use them 
in sets. Nor can I see any obvious design in all the 
nervous fibres from the flexors or extensors, or from any 
one muscle going to the brain, seeing that one or two fibres, 
or any equally simple communication between the brain and 



116 ON THE NERVOUS SYSTEM.- 

tlie segment or segments of the cord witL. wliicli they are 
connected would suffice. 

All considerations of the mode in which we use the 
muscles, and the power we have over them, would lead to 
the conclusion that the nerves are arranged into centres, 
and that we act upon these by our volition rather than upon 
the muscles, individually or directly. I believe this view 
of the subject will also be further strengthened if we con- 
sider the anatomy of a plexus and its probable uses. 

It has commonly been said that a plexus of nerves 
consists in an interchange of fibres of sensation and motion, 
for the purpose of transmitting the sensitive to the skin, 
and the motor fibres to the muscles ; and it is a curious 
anatomical fact that the nerve which supplies the muscle 
supplies, for the most part, the skin over the muscle, 
according to Mr. Hilton's dissections. Dr. Todd hints at 
the general use of a plexus for motion, but by no means 
develops his idea respecting it. Reverting again to the 
kind of power we have over the muscles, and the fact that 
plexuses are complicated in relation to the variety of move- 
ments of the parts supplied by the nerves subsequently sent 
off from them, it would seem that the use of a plexus is to 
bring the different segments of the cord into relation with 
groups of muscles. Thus, let A, B, C, D i-epresent so many 
segments of the cord, A being in connection with one 
group of muscles, B with another, and the same with C and 
D ; by acting upon the centre A we get a result correspond- 
ing to its connections, — we can conjoin it with B, or C, or 
D, or with any one or all of these, and get so many and so 
varied movements, as, for example, flexion with supination, 
equable throughout the entire act of flexion, or supination 
first and then flexion, or flexion first and then supination, 
and so with every other possible muscular movement, by 
conjoining the various segments, and acting upon them in 
different times, as we should play on the keys of an instru- 
ment. 

A plexus, therefore, must be regarded as a necessary 
part of the segmental symmetry of the cord — a necessary 
condition for combination and arrangement, although, on 
the hypothesis of our acting directly upon the muscles, one 



ON THE NERVOUS SYSTEM. 117 

can see no necessity for such an intercommunication of the 
roots. 

As confirming this view of the use of a plexus, I may- 
refer to the paralysing effects of injury of one of the roots 
of a plexus. If a nerve be divided before entering a plexus 
we do not produce paralysis of any one muscle, but a 
general diminution of power in the whole. 

As still accumulative evidence of this zonal symmetry of 
the nervous system, I would submit to your consideration 
the facts so notorious of the crossed action of the hemi- 
spheres on the cord. 

It is well known that injury of one hemisphere paralyses 
the opposite side of the body ; but there is at least one 
exception, and that is the third nerve, which is under the 
influence of the hemisphere of the same side, I shall give 
evidence of this in my remarks on hemiplegia. On con- 
sidering this curious disposition of parts, the first question 
that forces itself upon the mind is, why is there a decussa- 
tion at all ? and, secondly, why is the third nerve an 
exception ? 

Proceeding upon the belief that the spinal system is chiefly 
for motion, consisting of many segments, whose parts have 
a definite arrangement and relation, we are naturally led to 
inquire into the means whereby we are enabled to employ 
it. It will be readily conceded, that a previous knowledge 
of the mechanism itself can be no guide to us, inasmuch as 
but few persons have any, even the most vague, idea of its 
existence ; and with those who have an anatomical acquaint- 
ance with it, a contemplation or consideration of its parts 
forms no link in the chain. The phenomena of volition 
are intention — result, the sensation guiding to the end with- 
out any calculation of the aptness or adjustment of the 
means. 

The will produces its effects under the guidance of sensa- 
tion. I would illustrate this by referring to the muscular 
movement of the eyes and the phenomena of vision. The 
eye is directed to objects by two pair of nerves, the third 
and the sixth, the former being, as I have stated above, an 
exception to the crossed influence of the brain, and, as it 
would seem, for a very mechanical reason. Suppose any 



118 ON THE NERVOUS SYSTEM. 

impression affects tlie two eyes equally, the third nerve and 
the sixth adjust the eye to a due convergence upon it^ and 
we get an equable motion of the two globes ; but again, let 
the object be placed on the right or left side : we now re- 
quire, in order to direct the eyes to it, the conjoined action 
of the third nerve of one side with the sixth of the opposite. 
As the optic nerves manifest a decussating result, the object 
being most distinctly perceived by the nearest eye, for illus- 
tration, say the right, will transmit its impression to the left 
hemisphere, which will re-act upon the third nerve of the 
left side and the spinal centres of the right, comprising the 
sixth ; both eyes will be immediately directed to the right, 
the head turned thitherward also ; and, if necessary, by a 
movement of the right arm any approaching injury repelled. 
But if we suppose any other disposition, viz. that there 
should be no decussation, or that the third nerve should not 
be an exception, the beauty of the existing arrangement 
becomes especially obvious. As the body is now constituted 
if the object affects both eyes equally, and, consequently, 
both hemispheres equally, we have a conjoined action of the 
recti muscles of both eyes ; if, by the lateral position of 
one object, one hemisphere be affected, which will, from the 
decussation of the optic nerves, be that opposite to the ob- 
ject, we must have such an arrangement, that this hemis- 
phere can act reversely on segments of the cord. Hence 
do we find all the phenomena placed in a beautiful circle of 
relations. Thus, proceeding from the external object, the 
ray of light affects the nearest eye ; this, transmits its 
affection to the opposite hemisphere ; this, in its turn, re- 
acts upon the spinal segments in connection with it, viz. the 
third of its own side, and the segments of the opposite turn- 
ing both eyes, and directing the upper extremity, if necessary, 
to the object, and returning to the point whence we set out. 
In regard to this decussation, there is another fact worthy 
of consideration and which has been spoken of by others, 
viz. that the nerves placed above the point at which the 
decussating fibres cross from side to side, are as much 
subject to the law of inverse action as the nerves below. 
The seventh is an example. That this should be so, cannot 
be adduced as anything strange, if we regard the symmetry 



ON THE NERVOUS SYSTEM. 1.19 

of the segments after the manner here maintained ; for as 
such a crossed influence seems even necessary, as I have 
striven just now to show, it remains to consider what part 
would be most appropriate for the placing of the commissu- 
ral fibres ; and out of this arises a principle of great interest 
in regard to the exact point of the decussation. It is well 
known that hemispheric lesions, producing hemiplegia, 
affect the upper than the lower extremity, and the seventh 
and eighth nerves with the lingual are generally less affected 
than the nerves of either the arm or leg. The paralysing 
influence is, therefore, not equally distributed through the 
opposite side ; it is felt most severely in the parts which lie 
in the direction of the decussating fibres. Hence, had the 
commissure been from the summit of the segments of the 
spinal system and the same ill effects followed as we now 
know to result from cerebral lesion, would there not have 
been a much greater depression of the respiratory centres 
under cerebral injury, than is now produced ? And is 
there not a conservative adjustment in this particular posi- 
tion of the decussation, as well as in the decussation itself 
by which the respiratory centres are placed out of the line 
of action of the hemispheres, on the segments of the cord. 

The relation of sensation to the reflex movements is in 
the higher animals a complicated one ; and, whilst we admit 
the principle laid down by Hall, that it does not form any 
necessary part of excito-motor phenomena in their simplest 
condition, yet are there others in which the sensation is 
intimately and essentially precedent to the movement. 

The unity of organisation in man and the higher animals 
is such, that the condition of one part may react through 
the whole ; and this is strikingly demonstrated in the 
nervous system, in the central parts of which, although the 
same symmetry and anatomical relations may exist as in the 
lower animals, yet there is not by any means the same phy- 
siological independence. In the development of the parts 
of the human body, there are many relations shadowed forth 
which tend to show that it has a symmetry like the lowest 
animal forms ; and there is coincident with these immature 
states, the same independence of function. I call attention 
here to these well-known facts as confirmatory of a distinct 



120 ON THE NERVOUS SYSTEM. 

spinal system ; for^ whilst we must admit, that in the adult the 
nervous segments have less independence than in the fcetus, 
as proved by the phenomena of anencephalic monsters, and 
the results of craniotomy ; yet we may not deny to the adult 
the same symmetry as the foetus — the same arrangement of 
the active parts. I might, perhaps, adduce the foetal move- 
ments in proof of the excitability of the spinal centres, for, 
I think, they cannot be regarded as voluntary. If it be 
true, that the tissues in their development pass through 
phases of lower organic forms, we may expect the same 
independence of action to be coincident with these transi- 
tory conditions, as is found in those permanent states. I 
had a striking confirmation of this principle in the heart of 
a foetus of the fourth month. It was expelled prematurely 
about 5 o'clock one summer's afternoon, and, at 8 o'clock in 
the evening, I proceeded to open the thorax, in order to inject 
the minute terminations of the bronchial tubes, and, to my 
surprise, I found the heart to possess some irritability ; it 
contracted on being pricked with a needle after the manner 
of a fish's or reptile's heart when it has become so exhausted 
as to have lost its rythmic movements. This muscular irri- 
tability was like that of the cold-blooded animals ; nor can 
we doubt that its spinal segments had the same relations. 

There is a close subjection of motion to sensation in the 
action of the muscles of expression. I refer to those move- 
ments which have been called emotional, and which are as 
directly excito-motor as any, with this peculiarity, that emotion, 
or sensation, forms a necessary part. If we style the spinal 
movements mechanical, they are jpsychico -mechanical. 

The combination of sensation with voluntary muscular 
movements has, by Volkman, been shown to be the source of 
our knowledge of locality and direction. It is not to my 
purpose here to consider how he has applied this to visual 
direction and position of objects ; but I may just mention, 
that it has long seemed to me obvious, and I have long so 
taught it in lectures, that, as it is by the muscular move- 
ments of the upper extremity that we test the direction of 
any force acting upon the sensitive nerves of the fingers, so 
it is, by the contraction of the muscles attached to the eye, 
that we tell the position of any object which sends its rays 



ON THE NERV^OUS SYSTEM. 121 

to the retina. If the object be placed above, we use the 
superior recti ; if below, the layer ; if to the right, the 
muscles of the right side. 

The great discovery made by Sir G. Bell, that the poste- 
rior nerves of the cord were for sensation, and the anterior 
for motion, led him to express his belief that the columns 
of the cord itself had corresponding functions. Nor would 
it be easy to admit the contrary, if there were any grounds 
for believing that the columns were continuous with the 
nerves, and formed by them ; but as I have, at the begin- 
ning of this lecture, attempted to prove such an opinion is 
not founded upon observation, and although experiments 
devised for the proof of this opinion may seem to be affir- 
mative of the separate function of the columns, yet one 
must object to them as extremely fallacious^ considering the 
oblique origin of the nerves from the segments of the cord. 
Nor are experiments at all conclusive, inasmuch as very dif- 
ferent results have been obtained. Amongst modern physi- 
ologists, such an exclusive function is no longer maintained ; 
but as yet no general law has been enunciated which shall 
apply to pathological conditions. I am of opinion that the 
cases on record of local lesion of the cord will warrant the 
conclusion that the law demonstrated of the nerves does 
not obtain in the columns ; that neither the anterior nor the 
posterior columns have special functions in reference to sensa- 
tion or motion. And whilst, on the supposition of continuity 
of fibres upwards in the cord to the bi^ain, such a separate 
office of the columns seems inevitable, so, on the other hand, if 
it can be proved that they have no such function, we have an 
argument for the segmental symmetry and for that theory 
which is now generally admitted, of the fibres of the cord being 
commissural, uniting and weaving into a system these many 
centres for muscular action, and adapting them to our use. 

From this general survey, I hope, in my next lecture, to 
pass to the consideration of paraplegia ; and my endeavour 
will be to show, that there are at least three forms of this 
affection, which are accompanied with distinctive symptoms, 
and that the phenomena presented by paraplegia greatly 
favour this zonal and independent symmetry of the spinal 
system and the commissural function of the columns. 



122 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE II. 

PARAPLEGIA. 

One of the chief objects of this inquiry into the phenomena 
of paraplegia which I propose to myself, is to show that 
there is, according to its different forms, a different degree 
and kind of angesthesis ; in some cases the loss of motion 
being nearly complete, with but little and always less affec- 
tion of the nerves of common sensation ; in others, the loss 
of sensation preponderating over that of motion. 

That in paraplegia, resulting from local lesion of the cord, 
whether situated in the anterior or ^posterior columns, or 
affecting the whole substance equally, there is more paralysis 
than anaesthesia. That when there is preponderating affec- 
tion of the nerves of sensation, we may not anticipate that 
a post-mortem examination will show any limited lesion of 
the cord in any segment ; for in such cases the disease often 
arises from peripheral changes in the nerves, or from con- 
ditions of the central organs not recognisable by our usual 
methods of investigation, yet often associated with morbid 
accumulations of fluid in the ventricles of the brain, sub- 
arachnoid space, and opalescence of the membranes. 

Paraplegia, arising from injury to the cord through 
mechanical violence is extremely common. For the most 
part, the effects of the injury are immediate, motion and 
sensation being for the time, greatly affected or entirely- 
lost. If the lesion be less than to produce division or dis- 
organisation of the whole cord, although there may be 
considerable anaesthesia immediately following the accident 
yet the sensitive nerves, after a time, recover their function, 
though the paralysis may continue ; and this mode of 
recovery is, in such cases, universal. 

Before giving the records of the simplest cases of para- 
plegia which prove the positions I have laid down, I shall 
quote the experience of Mr. Earle, whose excellent article 
on paraplegia (in the thirteenth volume of the ' Med.-Chir. 
Trans.') I shall again have occasion to refer to. " In spinal 



PARAPLEGIA. 123 

affections," says he, *' sensation will often remain perfect 
after a total loss of the locomotive powers.'' So Sir B. 
Brodie, " when recovery takes place the restoration of 
insensibility usually precedes that of the power of voluntary 
motion, so that the patient may be quite sensible of external 
impressions while he is still incapable of employing his 
muscles for any useful purpose. The last observations 
apply equally to all cases, whether the spinal cord has 
suffered from concussion or from the pressure of displaced 
vertebrae." 

One of the great causes of our little advance in the study 
of nervous affections seems to me to have arisen from a 
tacit assumption that the phenomena were too uncertain 
and varying to admit of any general expression. Dr. 
Abercrombie seems to have striven to place, side by side, 
cases which should set at defiance all law, nor has he 
attempted to reconcile the discrepancies. But all will admit 
that to rest satisfied with this would be to take too narrow 
a view of the subject, for here, as elsewhere, there can be 
nothing- variable ; the order and relation of the phenomena 
must be as definite as in the inorganic world, though the 
conditions may often be so complex and interwoven as to 
elude our explanation. What is true of one case must be 
equally true of another like it ; yet this truism has hardly 
been admitted in nervous pathology. My endeavour, there- 
fore, to establish some general laws, if fruitless, must still, 
I think, be in the right direction. 

In paraplegia arising from the lesion of the cord, whether 
the anterior or posterior columns, or the cord generally, he 
affected, there is greater loss of motion than sensation. In 
proof of this, I shall refer to several well-known cases of 
disease of the columns. I may be allowed to premise, that 
it did not seem to me necessary to give cases in the full 
details with which they have been recorded by their various 
authors, for other purposes, although I have been careful 
not to omit any particulars which could bear upon the 
question here in consideration. In the ' Medico- Chirurgical 
Transactions,' for 1842, Dr. Webster gives a case of para- 
plegia, arising from inflammatory softening of the cervical 
portion of the medulla spinalis, affecting generally the 



124 DISEASES OF THE NERVOUS SYSTEM. 

whole structure of the cord and its membranes ; although 
from minute investigation of the diseased parts subsequently 
by Dr. Todd, it seemed that the posterior columns had most 
suffered. The individual affected had been, for many 
months totally deprived of the jpower of motion below the 
seat of the disease, yet his sensation was perfect throughout 
the entire surface of the body, with the exception of an over- 
sensibility of the affected parts, towards the end of the 
malady, which, together with many subjective sensations of 
heat and cold through the surface, although there was no 
change of the temperature of the external medium, excited 
the curiosity ol: those who watched the case, expecting to 
find some particular portion of the cord alone affected. As 
the writer tells us in his remarks on the case, " This 
instructive and interesting example of disease of the nervous 
system excited, as well it might, much attention in all those 
who witnessed its progress ; and they, along with myself 
confidently hoped that the pathological appearances met with 
on dissection would be such as to explain satisfactorily the 
rationale of the peculiar symptoms which the malady 
exhibited during the patient's protracted and severe suffer- 
ings, more especially in regard to those remarkable features 
characterising the case, namely, that whilst sensation 
remained unimpaired, voluntary motion was totally sus- 
pended ; because, should these anticipations be realised by 
the post-mortem examination, some important physiological 
truths would have been elicited. It is clear from these 
observations that an impression existed in the minds of those 
who witnessed this case, that the columns did subserve to 
motion and sensation ; but the result of the post-mortem 
examination by no means favoured such a theory, for not 
only were the posterior columns gi'eatly diseased, but there 
was a general affection of the whole cord and its membranes. 

James P — , get. 58, a farm-bailifE, was admitted into Guy's, under Dr. 
Babington, in the year 1845. He had enjoyed very good health until the 
autumn of the year previous, it now being spring ; he then began to complain 
of weakness in the legs and spasmodic constriction of the abdomen, as if a 
cord was passed tightly round the waist ; he never had a fall, nor any other 
injury to the back. On his admission there was not entire inability to move 
the legs, but they were very weak, the degree of the paralytic afBection 



PARAPLEGIA. 125 

varying. One of the points of most obvious remark was tlie tendency to 
spasmodic action of the diaphragm under emotions, or on touching the abdo- 
minal walls. There was no perce'ptihle dimintdion of sensation. He was 
treated by nervine tonics, as zinc, together with counter-irritation by the 
ferrum candens, and the progress of the case was marked by variable 
improvement and relapse, the power over the legs becoming entirely lost, 
but the sensibility not being to any marked degree affected ; and, on a post- 
mortem examination, there was no lesion of the brain nor of the parts about 
the spine. The entire substance of the cord in the middle of the dorsal 
region was soft and diffluent, and of a dull, opaque-white colour. 

The case recorded by Mr. Stanley, and which has been 
so often quoted, may be adduced here in proof of the 
assertion, that disease of the substance of the cord uncom- 
plicated, produces greater loss of motion than sensation. 

The patient was a man aged 44. The disease had begun gradually without 
any previous injury, and resulted in complete inability of motion, whilst 
there was, at the same time, not the least discoverable impairment of sensa- 
tion. The substance of the cord through its posterior half and columns, and 
in its entire length from the pons to the lower end, had become of a dark 
brown colour, and was very soft, whilst the anterior part had its due colour 
and consistence. The membranes were healthy, with a slight excess of the 
rachidian fluid. Mr. Stanley remarks : — " We cannot, .in the present state 
of our knowledge, satisfactorily transfer the same view of the distinctness 
of function of the corresponding columns of nervous matter composing the 
spinal cord (as obtains for the roots of the nerves)." It is the object of these 
remarks to show that such a law does not hold." 

Dr. Budd has recorded the following case : 

E,. H. — , sailor, aged 17. In August, 1837, received a severe blow on 
his back from the boom of his ship, which did not, however, disable him ; he 
continued his work as usual. From that time he suffered occasional pain of 
the loins, and weakness in the back, especially when stooping. This con- 
tinued, without other complaint, until the beginning of December, when he 
began to experience difficulty in running. 

On the 8th of January he was admitted into the Seamen's Hospital. On 
admission his lower extremities were observed to be in extension and very 
rigid, with sensation unimpaired, except slight numbness of the thighs. 

In the beginning of April profuse haemoptysis took place, and was soon 
followed by other symptoms of phthisis. His intellect had continued 
unimpaired ; the lower extremities quite deprived of voluntary power, but 
with sensation unaffected. 

On examination after death, the curvature of the back was found to be 
formed by prominence of the dorsal vertebrae, from the fifth to the ninth 
inclusive. 

As soon as the laminae of the vei-tebrse were divided, a small quantity of 



126 DISEASES OF THE NERVOUS SYSTEM. 

yellow pus oozed out from the right side of the spinal marrow, exterior to 
the dura mater. 

The dura mater, for the space of an inch and a-half corresponding to the 
most projecting portion of the spine, had a dark greyish stain externally, and 
was much more vascular than the portion above or below the curvature. 

The diameter of the cord was considerably smaller in the portion corre- 
sponding to the curvature than in any other part throughout its whole 
length. 

There was no pus in the sheath. 

The cord was of natural size, and a portion about two inches in length, 
corresponding to the curvature, softened in the posterior columns. The 
tissue was not diffluent, but became flaky and partially dissolved when a 
small and gentle cun-ent of water was poured on it. This did not happen 
when a like current was similarly directed on other portions of the cord. 
This breaking of the tissue was much more marked in the posterior than 
in the anterior columns, which were scarcely, if at all, softened, and resisted 
considerable traction. 

Under the heading " Undefined Suppuration of the Cord/' 
Aberci'ombie gives three cases, in neither of which is there 
any mention of the state of the sensation, although, in his 
other reports of similar affections, he is careful to note when 
the anfesthesia has been to any degree marked. 

I might go through every case recorded by this author, 
and show, that there is not one in which, from lesion of the 
substance of the cord, sensation was alone affected, or in 
which the anaesthesia prevailed over the paralysis. And 
here I would remark, that whilst the cases I have given 
have been detailed, in some instances, to show that the 
posterior columns were not for sensation, no general deduc- 
tion has, so far as as I am acquainted, been drawn from 
them. 

The following cases illustrate the same principle with 
variable seat of the lesion. 

A man aged 36. Paraplegia from fall ; complete loss of motion in lower 
limbs, without loss of feeling. Post-mortem. — Extensive ramollissement of 
body of cord, affecting anterior columns chiefly ; the posterior columns 
softened in many places, though in smaller degree. (Abercrombie, 129th 
case.) 

In a case by OUiver. Gradual palsy of lower extremities ; patient bed- 
ridden for seven years ; legs drawn up to the body, entirely motionless, but 
preserved their feeling. Post-mortem. — Extensive ramollissement of upper 
part of cord, especially in the anterior pillars and corpora pyramidalia. 

In a case by M. RuUier. Gentleman, ait. 44. Curvature of spine, para- 



PARAPLEGIA. 127 

lytic flexion, and at length complete palsy of arms, which became rigid, 
contracted, and entirely motionless ; sensibility of parts not affected. Post- 
mortem. — Six inches of cervical portion of cord entirely diffluent, so that 
before membranes were opened it moved upwards and downwards like a 
fluid. This case is given by Abercrombie. 

Man set. 20. Complete paraplegia ; no diminution of sensibility. Post- 
mortem. — Disease of third, fourth, and fifth cervical vertebrae ; tuberculous 
disease of membranes at this part ; ramollissement, chiefly of anterior 
columns ; posterior slightly softened. Abercrombie, sect, v, case 3. 

Gentleman sst. 18. Perfect paraplegia, without loss of sensation. "There 
had never been the least attemjjt at motion of the lower extremities, but the 
sensibility remained." There is mention of numbness in this case ; but the 
quotation is in Abercrombie's own words, and this affection of the sensation 
will be subsequently considered. 

It might not appear necessary to quote cases of affection 
of the anterior columns, as they have been regarded as 
normal when the power of motion has been most affected : 
but they equally bear upon the question I am considering 
with those in which the posterior columns were the seat of 
the disease ; forasmuch as both being accompanied by the 
same symptoms, neither can be regarded as proof of the 
special functions of the parts. And whilst it must be 
admitted that paralysis existed beyond anaesthesia, when the 
anterior columns were affected, it cannot be inferred that 
this was because the anterior columns were for motion, 
inasmuch as the same occurred when the posterior columns 
were the seat of the disease. 

The following case from Dr. Bright's reports may, I think, 
be adduced as bearing on this question, although he refers 
the paraplegia without anaesthesia to the position of the 
lesion ; but the preceding remarks appear to me to show 
that such is not the explanation. 

William B — , set. 20, was admitted under Dr. Bright into Guy's, August 
l8th, 1844. About six weeks before, without any cause of which he was 
aware, he began to feel pain in his neck, close to the head, which had 
increased, with some stiffness of the part. At the time of his admission his 
head was bent forward, so that the chin approached the upper part of the 
sternum ; there was almost complete hemiplegia on the right side, and some 
flying pain, which he called rheumatic. He complained of pain when the 
vertebrse of the neck were pressed, and there was an apparent displacement 
or slight in'egularity in the spinous processes of that part. Leeches were 
applied, and local applications made to the nape of the neck. 



128 DISEASES OF THE NERVOUS SYSTEM. 

At the end of November (three months) the other (the left) leg became 
much affected. 

In January (five months) he was unable to walk without assistance. He 
complained that his legs felt asleep, hut they retained their sensation. 
He died on the 8th of February, the report stating that on the day previous 
though quite sensible, he was unable to move any part of his body. 

The principal post-mortem appearances were confined to the processus 
dentatus, which, by its enlargement and displacement, had contracted the 
foramen very much. ' At a point where the pressure was made, the medul- 
lary matter of the spine had assumed a darker colour, to the extent of about 
a pea, and was apparently vascular. It is to be remarked, says Dr. Bright, 
that whilst motion was destroyed sensation remained perfect — a fact which 
may be easily accounted for when we consider that the processus dentatus 
was the part chiefly diseased, and necessarily made pressure on the anterior 
part of the cord. 

But, inasmuch as sensation remains perfect when the 
disease is general, or on the posterior part, this case cannot 
be adduced in favour of the columns having especial functions. 

In the ninth Volume of the ' Med.-Chir. Trans.,' Dr. 
Bostock has given a case of universal paralysis, of which 
the following is an outline ; and I quote it for the purpose 
of showing that general affection of the cord in this, as in 
the other cases quoted, manifests the same law in regard 
to anaesthesia and paralysis. 

M. H — , a middle-sized and well-formed man, between 30 and 40 years of 
age. Had enjoyed good health. Applied for medical advice in consequence 
of a pain which he experienced in one of the lower extremities. Its seat was 
on the outside, and a little above the knee, but it sometimes shot up to the 
hip. He mentioned that he had had a slight fall, but it seemed so unimpor- 
tant that he attached little to it. 

After two months the power of moving the limb was perceptibly dimi- 
nished, and in the next two the complaints continued slowly to increase. 
The limb possessed its full share of sensibility and was of the natural 
temperature, but he lost more and more the command over its motions. 
There was no pain in the trunk, nor could disease be detected in the spine. 
In two months more the other limb was similarly affected. There was no 
numbness, but shortly after this period a new affection made its appearance, 
— a difficulty of the articulation of particular words, and for the next four 
months the affection of the speech and of the limbs continued to increase, 
so'that he became unable to move without assistance, and his power of utter- 
ance was nearly lost ; and eight months afterwards he first complained of 
pain in the back of the head and neck, and the paralysis of the upper 
extremities and affection of the muscles of deglutition supervened. Not- 
withstanding this loss of voluntary power, there was no numbness nor insen- 



PARAPLEGIA. 129 

sibilityofany part of the body, neither to mechanical impressions nor changes 
of temperature. All the external senses and mental faculties remained 
unimpaired. He dragged on a wretched existence for six months, and died 
exhausted, — his senses, special and general, remaining unimpaired. 

Post-mortem. — We began by examining the brain, and every part of it 
was most minutely scrutinized, but without our meeting with any appear- 
ance which could be considered morbid. After a veiy accurate survey of 
every part, we thought we observed a slight furrow across the spinal cord, 
as if it had been compressed by a transverse ligature, and this in a place 
where it passes under the ring of the atlas ; and, upon attentively noticing 
this part of the bone, it appeared a little thickened and of a yellowish colour. 

Very numerous cases are on record of pressure on the 
cord, from tumours, hydatids, &c., in all of which loss of 
motion accompanied loss of sensation, when this latter 
formed part of the symptoms ; but I cannot find any cases 
of pressure or disorganisation uncomplicated, in which the 
loss of sensation preponderated, or in which there was simple 
loss of sensation. 

My attention has now for years been much given to post- 
mortem appearances ; but I have not met with cases which 
controvert my position, nor are there amongst the numerous 
cases of lesion of the cord which are contained in the records 
of this hospital, any which show that one part or column of 
the cord when affected, is attended with anaesthesia without 
loss of motion, though as we have seen, the reverse often 
happens. 

If it is admitted that these facts warrant the conclusion 
that seems to me fairly to flow from them, we have therein 
another argument in favour of the zonal symmetry I advo- 
cated in my last lecture. If we admit that this spinal 
system, in its various segments, can act under the form of 
an excito-motor system, which necessitates continuity of 
action from incident to reflecto-motor nerve, we cannot, I 
think, even suppose in these segments two centres ; one, 
namely, for receiving the impression from without, and the 
other for exciting the movement in the muscles. Nor does 
there seem to me any stronger grounds for admitting 
separate centres for motion and sensation in the brain than 
in the cord. How fallacious soever these remarks may be, 
yet the facts seem to oppose the assumption that there are 
such sensory and motor centres, distinct from each other. 

9 



130 DISEASES OF THE NERVOUS SYSTEM. 

In pursuance o£ my subject I have next to call attention 
to those cases of paraplegia in which there is much greater 
loss of sensation than of motion ; and far from finding them 
contradictory of the former, or anomalous, they seem naturally 
to arrange themselves into distinct classes. Before treating 
of the two great divisions of such cases I would observe 
that in paraplegia from disease about the spine the nerves, 
as they pass to the cord, are sometimes implicated, aud we 
find on a post-mortem examination sufficient explanation of 
what, carelessly observed, might seem to be an exception to 
the rule laid down. Thus in the case of the Count de 
Lordat, mentioned by Abercrombie, a paralytic affection of 
the left arm followed an injury to the neck from a fall, and 
the opposite arm became numb. On a post-mortem exami- 
nation, together with induration of the cord, there was a 
compact and tendinous condition of the cervical nerves, oiving 
to thicJcening of the membranes covering them. 

In some cases of disorganisation of the spinal centres 
numbness or other affection of the sensation may precede or 
accompany the disorganising process and yet, even as the 
paralysis increases, the state of the sensation shall improve 
and become quite normal. It would seem, from the simi- 
larity of such cases to the results of concussion of the spine, 
in which the sensibility returns after a few days, as if the 
onset of the local disorder produced the condition of concus- 
sion, destroying for a time the power of feeling which, so 
soon as the first shock of the inflammation is over, returns 
again. This is strikingly exemplified in those gradually 
extending affections of the cord in which anaesthesia is the 
precursor of paralysis, and then disappears. 

The first class of paraplegic affections, luith preponderating 
anaesthesia, are peripheral, beginning as impressions on the 
extremities of the sensitive nerves, the muscular movements 
suffering subsequently. The efforts of modern physiology 
have been directed to the elucidating and setting forth the 
functional value of each particular part of our bodies, and 
its success has nowhere been greater than in regard to the 
nervous system. We no longer regard nerve as a mere 
conductor of an influence received from the spinal cord ; it 
is in itself as active, according to its particular function, as 






PARAPLEGIA. 131 

the centre to which it is attached or the muscle with which 
it is connected. The prevailing views in physics Avill find 
their way into every branch of natural study ; hence we 
talked for a time of the nervous fluid, and there were theories 
to show that the nervous fluid is probably a highly subtil 
one, allied to the electrical. But electrical fluids expressed 
no more than an hypothesis, and we now regard the con- 
ducting wire as so conducting by virtue of its active 
molecular forces. We alter its physical state and we alter 
its power of conduction, and this reacts through the series. 
This great advance in physics has gone hand in hand with 
the discoveries in neurophysiology. Nerve has the power 
of exciting muscle by virtue of its proper state of nutrition. 
This is proved by exhausting a nerve. After leaving it 
at rest for a time it recovers itself, although previously 
divided from its centre. 

The nerves, in their distribution through the tissues, 
make up a very widely extended area of nervous substance, 
whose due nutrition and otherwise healthy condition is neces- 
sary to a proper exercise of its functions ; and, if we also 
take into consideration the position of its extreme parts far 
removed from the centre of circulation, and its susceptibility, 
we shall be disposed readily to admit that, from its extent, 
its position, and its delicacy, that it deserves our closest 
attention. 

Dr. Graves, who has treated on this subject, thus expresses 
himself : — " May not,'' says he, " the decay and withering 
of the nervous tree commence occasionally in its extreme 
branches ? and may not a blighting influence affect the 
latter, whilst the main trunk remains sound and unharmed ? 
Pathologists have, with respect to diseases of the nervous 
system, committed an error precisely similar to that which 
was so long prevalent with regard to diseases of the vascular 
system, for it is only lately that, in estimating the forces 
which influence the circulation in diseased parts, they have 
begun to appreciate the preponderating influence of the 
capillary vessels, independently of the heart's action and the 
vis a tergo. It is only lately that they have recognised the 
important truth, that diseased vascular action may commence 
in the circumference. He quotes as one of the most 



132 DISEASES OP THE NERVOtJS SYSTEM. 

remarkable of such, peripheral affections, the Epidemie de 
Paris of the spring of 1828, as follows : — '' Chomel has 
described this epidemic in the ninth number of the ' Journal 
Hebdomadaire/ and having witnessed it myself in the months 
of July and August for the same year, I can bear testimony 
to the accuracy of the description. It began (frequently 
in persons of good constitution) with sensations of pricking 
and severe pain in the integuments of the hands and feet, 
accompanied by so acute a degree of sensibility, that the 
patients could not bear those parts to be touched by the 
bedclothes. After some time, a few days or even a few 
hours, a diminution or even aholition of sensation took place 
in the affected members ; they became incapable of distin- 
guishing the shape, texture, or temperature of bodies, the 
power of motion declined, and, finally, they were observed 
to become altogether paralytic. The injury was not con- 
fined to the hands and feet alone, but, advancing with pro- 
gressive pace, extended over the whole of both extremities. 
Persons lay in bed powerless and helpless, and continued in 
this state for weeks and even months. Every I'emedy which 
the ingenuity of the French practitioners could suggest was 
tried and proved ineffectual. In some the stomach and 
bowels were deranged, and this affection terminated in a 
bad state of health, and even in death. In another, the 
vital organs, cerebral, respiratory, and digestive, were in 
the same state as before their illness, and their appetites 
were good, but still they remained paralytic. At last, at 
some period of the disease, motion and sensation gradually 
returned, and a recovery generally took place, although, in 
some instances, the paralysis was very capricious, vanishing 
and again reappearing. The French pathologists searched 
anxiously in the nervous centres for the cause of this strange 
disorder, hut could find none. There was no evident lesion 
(functional or organic) discoverable in the brain, cerebellum, 
or spinal marrow. 

The learned author from whom the above quotations are 
made uses these facts, with others, to prove that paraplegia 
may arise from diseased conditions of the nerves in their 
peripheral distribution ; and, whilst they are here introduced 
for a similar purpose, yet the chief object is to show that. 



PARAPLEGIA. 133 

in such cases, the nerves of sensation are often affected to 
a greater degree than those of motion, conti-ary to what 
occurs in diseases of the cord. The following are illustra- 
tions of peripheral paraplegia from cold, with prevailing 
loss of sensation : — 

David F — , set. 50, was admitted into Guy's, under Dr. Bright, in March, 
1838. By trade an engineer and wheelwright ; muscular. His present 
illness began seventeen years ago, with an aggravation five months since. 
His first symptom was mmnhness in the lower extremities, extending as 
high as the hip-joints. He had been at this period much exposed to wet and 
cold ; the poiver of motion was not in the least affected, and he continued 
to do his work without intermission. He could walk a distance of six miles 
without inconvenience. Five months since the numbness extended, and he 
attributes it'to his having about this period been engaged in working in a 
damp well ; after this, with the extension of the numbness, the power of 
motion in the legs became impaired, and the arms in some degree partici- 
pated. After being in the hospital for a short time he had twitchings in the 
lower limbs, and the power over the sphincters was diminished. His sym- 
ptoms increased to entire helplessness ; his legs became oedematous, the urine 
highly ammoniacal, and he died worn out. There was no section of the 
body. 

Although this case is incomplete, yet I think we may 
trace the peripheral affection of the nerves of common sensa- 
tion from cold and damp lasting without muscular weakness 
for seventeen years, and under fresh exposure the nervous 
centres beginning to suffer, followed by paralysis and all the 
evils attendant upon ramollissement of the cord. I need 
not here insist upon the fact that the nerves do suffer from 
cold, and that at parts far removed from its direct applica- 
tion, as in sciatica from standing on cold stones. 

The following case is given by Dr. Graves : — 

James M — , was admitted into the hospital labouring under paraplegia, 
which he attributed to cold and wet. About a month before admission he 
first perceived a stiffness of the great toe of the right foot, afterwards 
mi')nbness and coldness of the sole, and then of the leg as far as the knee, 
and dragging of the limb in walking. During the progression of the disease 
up along the thigh it commenced in the left foot, and after a few days he 
experienced almost coonplete paralysis of sensation in the right lower 
extremity, and a lesser degree in the left, accompanied by so much diminu- 
tion of the power of motion as to render him unable to walk withoiit support. 
About three weeks after the appearance of paralysis in the lower extremities 
the little finger of the right hand was attacked with numbness, which 
passed successively to the rest, attended by some loss of the sense of touch 



134 DISEASES OF THE NEEVOUS SYSTEM. 

and power of grasping objects. He has also liad retention of urine, and the 
bowels were obstinately constipated. There was no tenderness of any part 
of the spine ; he had no pain in the head ; his pupils were natural ; mind 
unaffected ; pi:lse, sleep, and appetite also, natural. " This case," says 
Dr. Graves, " I am convinced, had its origin in the extremities." 

Having thus shown that cases of paraplegia, with pre- 
vailing numbness, may arise from causes acting on the 
nerves themselves, I shall next call attention to a third class 
of paraplegic diseases, resulting from anxiety, mental depres- 
sion, irregular practices, and all attended with general 
diminution of the nervous force. 

The relation of the parts of the encephalon to the seg- 
ments of the cord, is one of great diflSculty to determine. I 
have observed that emotions of a depressing kind generally 
affect the lumbar portion of the cord very greatly. I have 
now a friend who has suffered from extreme susceptibility 
of the whole nervous system, resulting from great intellectual 
exertion ; and he describes to me that, under the least 
emotion, the shock felt in the loins is most appalling, seeming 
to take all the strength out of him. The trembling of the 
knees in fear is of the same kind. In the year 1820, Dr. 
Baillie published, in the ' Transactions of the College of 
Physicians,' ''Some Observations on Paraplegia of Adults," 
in which he states that where the spine has not suffered 
from outward violence, paraplegia most commonly depends 
upon a disease of the brain itself. Now, although I think 
our present state of nerve physiology, and the facts I have 
just read, will not warrant us in arriving at so general a 
conclusion, yet certainly a fair number of cases of paraplegia 
have an encephalic origin. 

Mr. Earle, in his excellent paper on paraplegia, made 
some most practical remarks on this form of the disease, 
and is the only writer, so far as I know, who has pointed 
out the condition of the sensation, as distinguishing it from 
paraplegia arising from primary affection of the cord. In 
the thirteenth volume of the ' Med. Chir. Trans.,' he says : 
" Paraplegia dependent upon disease in the brain generally 
occurs about the middle or a more advanced period of life 
than is usual in diseases of the bodies of the vertebras or 
the intervening fibro-cartilages ; its progress is more rapid 



PAKAPLEGIA. 135 

than the slow, insidious approach of symptoms from the 
latter diseases ; the affection is more general^ occasioning 
more or less paralysis of the upper and lower extremities ; 
and this will often take place in a very few days from the 
occurrence of the complaint. This disease happens much 
more frequently in men than women ; the gait of persons 
suffering from cerebral affection is peculiar and very differ- 
ent from that attendant on affections of the spine ; it very 
nearly resembles the vacillating steps of a drunkard. Such 
paralytic persons are incapable of walking in a direct line ; 
the limbs are loose, and thrown forward with an exertion 
of the whole body ; there is a great consciousness of feeble- 
ness in walking, and the greatest difficulty in turning round. 
The appearance of the eyes often much resembles those of 
a drunkard^ particularly when the patient is at all excited or 
anxious. The above similitude to the staggering steps of 
intoxication is readily understood, if we consider that it is 
the temporary disturbance of the brain from the congestion 
of its blood-vessels that deprives the drunkard of the power 
of directing his steps, and for the time induces a state 
bearing the closest resemblance to paraplegia." 

" Sensation is more impaired than in spinal affections, 
when it will often remain perfect after a total loss of the 
locomotive powers. This impaired sensation is often peculiar, 
imparting an idea of some foreign body, as a leather glove 
or stocking, being interposed. The patient appears to feel, 
if I may use the expression, through a false medium. The 
limbs are more wasted and flabby, without any spasmodic 
rigidity of the muscles, which so often occurs in affections 
of the spine. Although often accompanied with a torpid 
state of the bowels, aggravated, no doubt, by the impaired 
muscular power of the abdominal parietes, there has not, in 
any instance that I have witnessed, been any train of gastric 
symptoms similar to those which so constantly attend affec- 
tions of the spine, especially of the dorsal region." 

We are not, at present, in a condition to determine what 
is the precise state of the nervous system arising from exhaus- 
tion of its energies. It is one which leaves no obvious 
changes behind it, although its results are often permanent. 
Losses in trade, reverses of fortune, depressing emotions, too 



136 DISEASES OE THE NEEVOUS SYSTEM. 

mucli anxiety, too much study, and many similar causes, 
may so lessen the whole tone of the system as to produce 
angesthesia with paraplegic weakness, and leave no change 
behind ; or we find, as concomitants, sub-arachnoid and 
ventricular effusions, with wasting or other general altera- 
tions of the nervous substance. 

Although it cannot be denied that a preponderating weak- 
ness of the lower extremities may arise from mere local 
affections in the encephalon, especially when affecting the 
parts in the neighbourhood of the spine, yet, as such cases 
follow the law of local central lesion, in which motion suffers 
more than sensation, already considered, I need not allude 
to them here, my object being to point out those cases which 
militate against this law, and to prove that they have an 
especial morbid anatomy, consisting, when any appearances 
are evident, of general and passive changes, of fullness of 
the larger venous trunks, watery effusions with chronic and 
various general states of wasting, hardening or softening of 
the nervous substance ; changes which, though so seemingly 
opposite, may yet have the same result on the functions of 
the parts. 

There is good reason to believe that many of these changes 
are results rather than causes of the loss or diminution of 
function. We know that we cannot interfere with the func- 
tion of an organ without affecting its structure. If a duct 
be tied or obstructed, we get wasting or degeneration of the 
gland from which it comes, and I would venture to suggest 
whether something similar may not occur in the nervous 
tissue. These cases of paraplegia having an encephalic 
origin, and characterized during life by prevailing anaes- 
thesia, present to us general as opposed to local and isolated 
changes of structure, that is provided there be any obvious 
appearances at all, which sometimes there are not. 

The two following cases are from the abstract of an inter- 
esting paper on " Paraplegia,^' by Mr. Atholl Johnson, as I 
find it given in the ' Medico-Chirurgical Review,' 1842, and 
which are classed by him as under '' Paraplegia, cause not 
discovered by dissection : " 

Thomas B — , tet. 39, admitted into St. George's with paralysis of the 
lower extremities ; motion is not entirely lost, but greatly impaired. 



PARAPLEGIA. 137 

Sensation entirely lost at the soles of the feet, becoming less affected as 
you passed up the legs. Urine and f^ces passed involuntarily. States that 
the attack commenced three weeks ago with numbness of the feet and 
dulness of vision in the right eye. At present vision is perfect, and the 
pupils act naturally. Sloughs on the back. Soon after admission, a cough 
with muco-purulent expectoration, mixed with blood, came on. In six weeks 
he died. 

Post-mortem. — The body was much emaciated ; large and extensive 
sloughs over both hips and sacrum. There was a small quantity of fluid in 
the upper part of the theca, which had apparently dropped down from 
between the membranes of the brain. Spinal cord apparently healthy ; a 
slight alteration of colour and consistence was thought to be observed about 
opposite the first lumbar vertebra. The change, if any existed, was very 
slight. The sinuses of the brain contained a considerable quantity of dark 
blood ; some fluid in the ventricles. Structure of the cerebrum and cere- 
bellum apparently healthy. 

Anne C — , aet. 21, admitted with palsy of the lower extremities ; sensa- 
tion impaired, but not altogether lost; double vision occasionally ; incon- 
tinence of urine, but not of fteces ; sloughing of back rapidly came on, but 
which, by the greatest care, was prevented from extending. Under the 
remedies employed she improved gradually for some time, becoming able to 
retain her urine and fseces, and to move the leg slightly when in a recum- 
bent posture. The double vision still continued, though in a less degree ; 
suddenly, however, the back and hips began again to slough, the legs were 
drawn up convulsively close to the abdomen, vision became affected to a 
much greater degree, and there was violent pain in the head. She died at 
last, worn out by the profuse discharge from the back. On examination 
after death, the substance of the cerebrum was firm and natural ; it was, 
perhaps, rather wet when cut into. But little fluid in the ventricles. 
Substance of the anterior part of the middle lobe of the left hemisphere 
slightly softer than other parts. The cineritious substance was here of a pale 
colour ; the cerebellum, pons, crura cerebri, and optic nerves apparently 
healthy. A small quantity of fluid was effused external to the dura mater 
in the spinal canal, and a very small quantity within the the theca ; cord 
quite healthy. 

Some time since I had the opportunity of seeing the 
following case of paraplegia, which arose, apparently, from 
mental emotion, and in which no lesion was discoverable 
after death. I cannot state what was the condition of the 
sensation. 

Mary H — , set. 21, of delicate frame but healthy, was in her usual health 
until one day a medical man, to whom she had applied on account of a bursal 
enlargement at the back of the wrist, offered to disperse it. To this, though 
very fearful, she consented. He struck the wrist several times with a book, 



138 DISEASES OP THE NERVOUS SYSTEM. 

and gave her so much pain, and mental disquiet, that she fainted. The 
same day she took to her bed, complaining of weakness in her legs. She 
soon became completely paraplegic, and her back sloughed. After lingering 
for some months she died, and, on a most careful post-moitem examination, 
no disease could be discovered in the brain nor spinal cord, nor any visceral 
derangement to account for the paraplegia. 

It is in the experience of most to have seen cases of para- 
plegia in young women in whom post-mortem examination 
has not shown any local or general disease of the cord. In 
some of these congestive derangements of the kidneys have 
been found, with or without calculus in their pelves, and 
some have regarded these latter conditions, when present, 
as the exciting causes of the paraplegia, through impressions 
on the sympathetic nerves. It is not the object of this 
communication to enter upon such an inquiry, but I may 
express my belief that many of these renal affections in 
paraplegia are the result of the spinal affection. I do not 
here refer to those cases of kidney disease and stricture 
complicated with paraplegia, described by Mr. Stanley 
('Med.-Chir. Trans.,' 1833), in which he believes that the 
diseased kidneys communicate an impression to the spinal 
cord and nerves issuing from it. 

The following examples seem to belong to the class which 
might be termed eiicephalic paraplegia, which. I am here con- 
sidering, and illustrate the general symptoms presented by 
these cases, especially in reference to sensation. 

Henry C — , jet. 53, was admitted into Guy's with the following history 
and symptoms : — He is tall and of a spare frame, large, well-formed head ; 
attributes his present condition to losses in business and to irregularities, 
although of late he has been less dissipated. He has great weakness of 
memory. There is so much affection of the nerves of common sensation 
that in walking he does not seem to touch the ground, and the legs are so 
weak and faltering that it is with the greatest difficulty that he can support 
himself a few steps with a stick. He says he feels without weight, and finds 
it difficult to keep himself on the ground, for he seems to have a greater 
tendency to fly than to walk, though, indeed, he can effect the latter but a 
few steps only. 

The hands and forearms are also affected with numbness, especially the 
former, and there is weakness and awkwardness of movement, but less than 
of the legs. He can retain or pass at will the urine and fasces, but there is 
some diminution of power ; urine pale, large in quantity. The vision is 
impaired. 



PABAPLEGIA. 139 

Heat and cold are oppressive. Twilight is more agreeable than full day- 
light, which is too exciting, and leaves him with less command over his 
movements. If he attempts to read, the letters soon become confused. 

His memoiy is defective, his few weeks' residence in the hospital seeming 
to him a lifetime. 

Various tonics, as zinc, iron, shower-bath, electricity, were employed with- 
out any good result, and he remains much in the same condition. 

Sarah S — , set. 30. In the autumn of 1845, "whilst residing in Italy, 
where she had been for five years, began to complain of languor and 
indisposition to exeiiion, which she attributes to sedentary habits. 

The attack began by a feeling of numbness in the left leg and right arm ; 
also the vision of the left eye was impaired. In a short time the other 
extremities became similarly affected. At this time she could walk and 
grasp firmly, but could only imperfectly feel the floor, or tell when she held 
anything in her hand. After her return to England, which was in the 
spring following the autumn in which she was attacked, she became much 
worse, and was confined to her bed for five months. Galvanism in the course 
of the lower limbs restored her. She was then obliged to gain her liveli- 
hood by close application to her needle, and her present state is very 
unfavourable. I have watched her for a year. About two months since 
(two years from beginning of attack) her speech became faltering, and her 
eyesight very dim. The right arm and left leg are the worst, the left arm 
being not greatly affected ; still there is some numbness in the fingers, 
especially in the tips of the middle and ring finger. 

In attempting to walk, which she can do with slowness and caution, she 
has no sensation of touching the ground, but seems to tread on nothing. 
There is considerable impairment of sensation up to the knee, as if some soft 
and thick substance was covering the surface ; above the knees the sensation 
is good. 

The middle and ring fingers of each hand are more numb than the others, 
and the palm more than the back of the hand ; the numbness extends to the 
elbows. She has power over the bladder and rectum. The various remedies 
employed have not had any very decided effect. They have consisted of 
tonics and rest, with counter-irritants. 



The peculiar state of the sensation in this form of para- 
plegia was remarked^ as I have said above, by Mr. Earle. 
There is numbness and an affection of the nerves of common 
sensation, as if some substance interposed itself between the 
object and the skin, and the integuments feel as if bandaged. 
The paraplegic affection is in part owing to the affection of 
the sensation, so that the patient cannot direct the muscles, 
rather than to an actual weakness in their contraction. One 
patient told me he could not walk without looking at his 



140 DISEASES OF THE NEEVOUS SYSTEM. 

feet, because he felt as if the legs were cut off below the 
knees, and another because he had no apparent weight. 
With the numbness there is yet the perception of pricking 
or pinching of the integuments, and the numbness generally 
terminates in an undefined manner about the elbows, and 
just above or at the knees. Power over the bladder and 
rectum is not lost, except in extreme cases. 

There is often pain over the bead, some affection of vision, 
as dimness or muscse volitantes, noises in the ear ; and one 
peculiarity is that the most moderate pressure on the nerves, 
as from lying on the arm in bed, or sitting on the edge of a 
chair, will very speedily render the nerve completely anaes- 
thetic. In walking the patients complain of difficulty of 
keeping on the ground, which seems due to want of sensa- 
tion, which is necessary for directing the movement, as well 
as to the sudden contraction of the muscles. The morbid 
changes I have spoken of above are general rather than 
local, and, so far as I can find, afford no explanation of tbe 
peculiarity of the state of the sensation, although it seems 
probable such may depend upon disorder in or about the 
mesencephalon. 



LECTURE III. 

CERVICAL PARAPLEGIA HEMIPLEGIA. 

In the former lecture three forms of paraplegia were 
enumerated, in each of which there exists a characteristic 
condition of the sensation ; and cases were given which 
seemed to show, that when ansesthesia prevails over loss of 
power, we must not expect to find a local and circumscribed 
lesion of the cord, but that we should refer such cases to 
peripheral affections of the nervous expansion in the tissues 
or to a general though often inappreciable change of struc- 
ture of the myelencephalon. Before leaving the subject of 



CERVICAL PAEAPLEGIA HEMIPLEGIA. 141 

the former lecture, it seems necessary to call attention to a 
form of paraplegia particularly affecting the upper extre- 
mities. Five cases of this particular form of paraplegia 
have fallen under my observation, and several others are 
on record. The legs are sometimes not in any degree 
affected ; in all they are much less so than the arms. The 
muscles of the shoulder and upper arm are first implicated, 
and often alone affected. The disease may begin in both 
extremities at the same time, or, having begun on one side, 
may gradually pass across and affect the other. 

At the onset there may be pain and soreness of the 
muscles, but after the disease has existed for some time, 
there is no obvious modification of the sensation. The 
following examples will illustrate this affection. 

In the year 1830, Dr. Darvall recorded cases in which he 
designated " a peculiar species of paralysis,'^ and which, 
from the absence of any more distinctive term, and the rela- 
tion to paraplegia, may be classified under cervical para- 
plegia. 

The following is an abstract of Dr. Darvall's cases, after 
which I will add others : — 

" A washei-woman, who had been accustomed to cany heavy weights upon 
her arms, had paralysis, which was confined to the muscles which raise the 
OS humeri ; there was gi-eat emaciation of the deltoid ; she could move the 
limb only a few inches from the trunk, and this with great difficulty. 
Nevertheless she could bend the forearm upon the arm, and, to use her own 
expression, could do anything under the elbow. The hand had its full 
power. There was not the slightest symptom of affection of the head, nor, 
indeed, excepting this paralysis, did the patient appear to have the slightest 
ailment. The treatment instituted did no good, and she gradually lost the 
whole power of the upper exti'emities." 

" A porter in a cornf actor's warehouse, accustomed to move large bags of 
oats, &c. Incapacity limited to muscles which raise the arm, gradually 
invading the whole limb, and ending in total paralysis of both extremities. 
No pain was experienced in either of these cases. The state of the sensa- 
tion is not mentioned." 

" A man accustomed to carry heavy weights complained of severe pcdn in 
the left deltoid, and aftei-wards great weakness, in which the muscle was 
much wasted. Considering the pain to be rheumatic, acupuncture was tried, 
by the insertion of three needles into different parts of the deltoid. The 
result was most satisfactory ; the pain disappeared, and the muscle recovered 
its bulk." 

" A locksmith had been suffering from severe pain in the right shoulder 



142 DISEASES OF THE NERVOUS SYSTEM. 

for some time, wliich was relieved by colchicum, but the deltoid remained 
exceedingly flabby. Electricity soon restored tbe power." 

"Female. Left arm only affected. Loss of power beginning in the 
muscles of the shoulder, and gradually extending downwards for four 
months ; but she can do anything imder the elbow. Slight pain in the 
deltoid on pressure, or on moving the shoulder. Muscles of the arm much 
emaciated." 

Fanny J — , set. 28, admitted under Dr. Addison, February pth, 1848; 
a milliner, of delicate frame, fair complexion, regular habits ; has not been 
overworked ; catamenia regular ; health good, with the exception of occa- 
sional headaches, with considerable intervals of entire freedom. Five 
months ago she had one of her usual attacks, which continued two days, and 
after a week she had a general heaviness and weight in the head, with 
dizziness and giddiness. This was followed by rheumatic fever. The right 
arm soon became paralytic, then quickly afterwards the left, and lastly, 
there was weakness in the leg of the left side. She entirely lost the use of 
the upper extremities : they were not swollen nor very painful. After a 
short time her general symptoms of fever disappeared, with a great im- 
provement in the afEected leg, and some in the corresponding arm. The 
rio-ht arm remained perfectly motionless from the shoulder to the wrist ; 
there was some power in flexing the fingers. Her head is quite clear ; no 
affection of the muscles of the face nor of the nerves of special sense. 
The paralysed parts are bathed in profuse pei-spiration, and the right elbow 
is highly swollen. 

Tongue clean ; pulse 76 ; bowels regular. 

During the time she was in the house, the leg considerably improved, 
but still remained to a certain degree weak. The arms were very powerless, 
especially the right ; but the contrast between the muscles of the foreai'm 
and those of the shoulder was striking ; she experienced now and then shoot- 
ing pains in the arms, especially the left. 

Durino- the whole course of her case, she complained of pain about the head ; 
but this was peculiar, and seemed to originate in the upper part of the neck. 
There were several opinions as to the cause of this peculiar paralysis, some 
regarding it as the result of cerebral exhaustion, others thinking it was 
apoplectic. Dr. Addison, under whose care she was, considered it spinal, and 
the test of galvanism, from fifty pair of plates, showed great excitability of 
the muscles of the least affected arm. 

George R — , set. 32 ; admitted into Guy's under the care of Dr. 
Babington, for paralytic weakness and great wasting of the muscles of both 
arms, especially of the deltoid, supra and infra spinatus, biceps, and triceps. 
He says that six weeks ago he began to feel pain and aching in the shoulders, 
the right being first affected. He had considerable pain between the 
shoulders, and in the left breast. Quickly following these symptoms there 
was considerable wasting of the muscles, with accompanying soreness of 
them. For a short time after his admission the legs were weak, but this 
lasted for a few days only. There is now no obvious affection of sensation, 



CERVICAL PARAPLEGIA — HEMIPLEGIA. 143 

but he has had a slight and almost inappreciable sensation of numbness in 
one side of the face and about the soles of the feet, which has passed away. 
The muscles of the forearm are much stronger than those of the shoulder ; 
the latter are greatly wasted. There are no cerebral symptoms, no history of 
rheumatism, nor any obvious cause to account for the affection. He walks 
about with his arms hanging uselessly by his side. 

(This man, since the above report was made, has been on alternate days 
galvanised through the affected muscles, and is now rapidly improving.) 

Frederick S — , set. 27, was admitted under Dr. Babington into Guy's in 
the year 1847. His present affection, which is peculiar, began to show 
itself very gradually four years ago. He is of middle stature, and has been 
moderately robust, but now presents a remarkable atrophy of all the 
viuscles supplied by the brachial plexuses of both sides, and of the 
muscles of the bach at the tqjper part. His legs are unaffected, and so are 
the muscles of expression and deglutition. He is by trade a dyer of silks, 
and much exposed to vicissitudes of temperature ; the arms in his occupa- 
tion being uncovered, and alternately immersed in hot and cold liquors. 
The substances employed by him as dyer are chiefly iron and vegetable 
astringents. They do not seem to have affected his general health. There 
is no affection of sensation, no tenderness of the spine, nor any in the course 
of the nerves ; no affection of the brain. 

Digestion, secretion, and circulation normal. It is obvious in this case 
that the great inability to move the arms may be explained by their atro- 
phied condition, and the disease is strictly a form of muscular atrophy and 
consequent weakness. 

Dr. Bright, in his reports, gives the following case of 
" paraplegia connected with rheumatic gout : " 

Daniel McC — , aet. 45, a very large and athletic man ; a coal-shipper 
by occupation, and therefore greatly exposed to the vicissitudes of the 
weather. His general affection is entirely confined to his hands and arms, 
which are almost completely paralysed. His hands lie nearly powerless on 
his lap, and he has just power enough to raise his hands to his mouth, 
assisting himself by a kind of swinging motion of the body. No pain is 
experienced by rotation or nodding of the head, except a slight uneasiness 
low down in the necTc. He has rheumatic pains in the feet. The affection 
of the hands and arms has been coming on gradually for eight months, and 
he says he was affected in a similar way three years before, but, after six 
months, recovered so much as to be able to return to his laborious employ- 
ment. The back of the neck was blistered, and a few leeches applied daily 
to that part. He was ordered antim. opiate pill, with two grains of calo- 
mel twice a day, and occasional purgatives of colchicum wine and infusion 
of senna. However, very little improvement followed, and he continued 
the calomel until ptyalism was produced. Afterwards a fair trial was 
given to nux vomica, without any decidedly advantageous change. Still he 
seemed to gain ground, and expressed himself as being better. At length 
he became the subject of a most severe attack of acute rheumatism in the 



144 DISEASES OF THE NERVOUS SYSTEM. 

right arm and both the feet, which was treated by calomel, antimony, and 
opium. In a few weeks he left the house, free from all traces of his last 
attack, and so greatly relieved from his paralytic ailments as to intend re- 
turning to his laborious occupation. 

The paralytic affection illustrated by these cases is 
peculiar. The muscles of the shoulder and elbow are much 
more affected than those of the forearm. The paralysis may 
be limited to the deltoid for a long time^ and subsequently 
implicate other contiguous muscles. An arm, powerless in 
this particular affection, presents a remarkable contrast to 
the arm paralysed from apoplexy. In the former the fore- 
arm and the fingers are less affected than the parts above, 
whilst in the latter the reverse obtains. We have already 
seen that paralysis may arise from the centres, or from the 
nerves ; but many of these cases here described show a 
primary affection of the muscle, others hoth of the muscle 
and the nerve distributed to it : in either case it is probable 
that the neurilemma forms the medium through which the 
diseased action travels to affect adjacent muscles. A man 
ast. 56, came under my notice for a wasting and a weak- 
ness of the muscles which elevate the humerus ; the muscles 
of the forearm were of their normal size and strength. The 
account he gave was that, thirteen months previous, he had 
fallen and struck his shoulder, but the blow gave him no 
anxiety, and its immediate effects soon disappeared ; but 
after a month there came on very gradually weakness of the 
deltoid and of the muscles about the shoulder, supra-spinatus, 
&c. After eight months the opposite side began to be simi- 
larly affected ; helow the elbow the arms were quite healthy. 
There were no spinal or cerebral symptoms. The head was 
clear, the legs strong. Dr. Darwall's cases are of a similar 
kind, and probably arose from the injury to the muscle by 
carrying heavy weights on the shoulder. We have also 
given above examples of this muscular atrophy arising from 
cold and rheumatism, and one in which there was no obvious 
cause. Although I cannot venture to give an account of its 
exact pathology, yet may I express my belief that the mus- 
cular tissue is the primary seat of this disease. I have now 
a case under my care in which I have been able to trace a 
continuous extension of the disease through the deltoid. 



CERVICAL PARAPLEGIA — HEMIPLEGIA. 145 

beginning at its posterior edge. Soreness of the aifected 
muscles is an early symptom. ; this^ however, varies much, 
and is sometimes absent. The results of treatment also 
favour the same view. If taken early they seem very amen- 
able to treatment, and especially to electricity. Darwall 
found acupuncture of the muscle arrest the disease. That 
paralysis may arise from primary affection of the motor 
organ or muscle, there seems no reason to deny ; and it is 
more than probable that, in considering the causes of para- 
lysis, such a source has often been overlooked. Muscle, 
even during rest, is, to a certain extent, active, and its due 
nutrition and susceptibility to excitement are, to a great 
extent, dependent upon this action, which is kept up by the 
connection of the muscle with the centre through the nerve 
supplied to it. Muscles rapidly waste when the nervous 
trunk which runs to them is diseased, and irreparable atrophy 
of muscle may result from causes of a temporary kind acting 
upon the nerve ; hence the importance, in all cases where 
the muscular tone is interfered with, of supplying the stimu- 
lus of electricity to prevent the wasting which would other- 
wise follow upon the paralysis ; for, if we do not employ 
this means, we may find, to our dismay, that, although the 
nerve may be restored to its functions, it may have no fibre 
to excite. Some time since I met with an excellent illustra- 
tion of this principle in the case of a woman admitted under 
the care of Dr. Addison. She had had paralysis of the 
seventh nerve for many years ; the eye of the same side 
was permanently open, and the cheek flabby and fallen. 
She never had paralysis of any other part ; had been sub- 
ject to faceache from bad teeth, and attributed the paralysis 
to this. There had never been any discharge from the ear, 
nor any obvious cause of injury to the nerve. She died 
from affection of the chest, for which she was admitted. 

Post-mortem. — The medulla oblongata and cerebellum 
were removed with care, but no disease of either could be 
detected. The seventh nerve of the affected side was 
traced from its origin to its distribution, through the whole 
of its osseous course. It was not apparently wasted, and 
when examined by the microscope its tubules presented the 
usual appearance, and could be traced continuously. The 

10 



146 DISEASES OP THE NEEVOUS SYSTEM. 

muscles of tlie cheek were not distinguisliable ; no muscular 
fibre could be detected therein. 



Hemiplegia. 

In my first lecture I spoke of the extent of the decussating 
influence of the hemispheres on the spinal cord, and men- 
tioned what has been also remarked upon by others, that 
as the same law obtained equally for motion as for sensation, 
and as the number of fibres actually decussating was very 
small in comparison with the whole spinal fibres, we must 
regard those which did cross as commissural between brain 
and the segments of the cord, rather than as continuations 
of the nerves themselves. In applying this to the explana- 
tion of hemiplegia, it may be stated (although there are ex- 
ceptions, not yet accounted for) that if there be disorgani- 
sation of the hemisphere, whether affecting the anterior or 
posterior lobe, and implicating the optic thalamus or corpus 
striatum, singly or equally, if the lesion be of such an extent 
as to produce hemiplegia, there will be a greater affection of 
the upper than of the lower extremity, and a greater loss of 
motion tlian of sensation. If the lesion has been sudden, and 
both the upper and lower extremities are completely para- 
lysed, the leg will begin to improve before the arm, and the 
muscles nearest the trunk will regain their power first, — that 
is, the deltoid and flexors of the elbow before the muscles 
which move the fingers. This is so obvious and so constant 
that it may, I think, be laid down as the law of hemi- 
plegic paralysis having the encephalic origin I have spoken 
of. As regards sensation, it is sometimes abolished, as the 
intelligence also is for a few days following the attack, if the 
lesion has been sudden, but is soon recovered from ; the 
mode of its restoration being, like the recovery of muscular 
power, first in parts nearest the trunk, and first in the leg. 

The seventh nerve is, in the class of simple cases, less 
affected than any nerve of the hemiplegic side ; still it is 
generally to a slight degree paralysed, and the affection 
shows that it is subject to the law of crossed action ; and 
the same may be said of the lingual nerve. 

I mentioned in my first lecture that the third nerve was 



CERVICAL PARAPLEGIA HEMIPLEGIA. 147 

an exception, and probably the only exception, to the law of 
decussating effects ; and an attempt was made to show why 
this was, and how the exception seemed to point out the use 
of a decussation. I must now trouble you with some facts 
in proof of my position. 

In hemiplegia depending upon lesion of the hemisphere 
affecting the corpus striata and thalamus opticus the third 
nerve frequently does not suffer at all, the movements of the 
eye being- unaffected and the pupils acting equally. In 
looking over the reports of a great number of hemiplegic 
cases one is struck with the slight affection of the third 
nerve, so that it requires a great extent of research and 
observation to find examples illustrative of the point in 
question. 

It is now well established that the contractile power of 
the iris depends upon the third nerve, and equally certain 
that the act of contraction is excito-motor, and therefore in 
part governed by the state of the optic nerves. In studying 
the condition of the third nerve, therefore, it is necessary to 
have regard to the susceptibility of the retina. The follow- 
ing cases are given to show that the third nerve is affected 
on the side on which the cerebral lesion exists : 

Richard K — , set. 66. Sanguineous apoplexy ingravescent ; comatose ; 
breathing 26 ; pulse 64 ; entire paralytic resolution of the left side ; pupil 
dilated on the side opposite to the paralysis, that is on the side of the 
cerebral lesion. 

A. B — , ajt. 67. November 29th, 1846, symptoms of ingravescent 
apoplexy. On my first seeing him his right pupil was very much dilated, 
left small, as in sleep ; breathing 32, pulse 74 ; complete insensibility. It 
was difficult, from the condition of the muscles, to tell which side was most 
affected. Post-mortem. — Very large effusion into right hemisphere, 
probably beginning near substantia perforata lateralis. 

Paraplegia. Catherine T — , set. 56. Paralysis of left side, coming on in 
the course of two days, without loss of consciousness. Entire paralysis of 
arm and leg, and falling of the features on the same side. The opposite 
pupil (right) slightly the largest. She turns the eyes with greatest readi- 
ness to right side. 

Heviiplegia with symptoms of ramollissement. Female, set. 56. Pupils 
equal, and act on the stimulus of ligbt ; complete resolution of left side ; 
eyes directed to right. 

Acute hydrencephaloid affection. D. W — , set. 19. Partial consciousness ; 



148 DISEASES OP THE NERVOUS SYSTEM. 

breathing rather stertorous, 20 ; pulse 1 20 ; left side of body appears para- 
lysed ; eyes directed to the right, jactitating motion of this side, right pupil 
largest, vision lost. 

Hemiplegic weakness coming on during sleep. Margaret N — , set. 28. 
Partial paralysis of left side, most affecting the arm ; the sight of left eye 
impaired, and the pupil of this eye rather the largest ; the motions of the 
eye are nearly perfect, slight ptosis of right eyelid. In this case the state 
of the pupil is the revei'se of that in the apoplectic cases, depending upon 
the condition of the retina, but the partial ptosis in the side opposite the 
hemiplegia proves the law. 

Hemiplegia, ten months' standing, attack sudden. Richard L — . Hemi- 
plegia of right side, gradual improvement ; turns his eyes most readily to 
left. 

Chronic brain disease. W. M — , set. 27. Hemiplegia, weakness of right 
side, with some anaesthesia, pupils both dilated, left least active. 

These cases, which I might add to, will be sufficient to 
prove the rule I wish to establish. The investigation is 
difficult from the reaction, as I have before said, of the 
retina and the iris, and the uncomplicated examples are not 
common. The facts may, so far as I have observed, be 
reduced to : 

1. Pupil largest on side of disease, vision being lost. 

2. Eyes turned from paralysed side. 

3. Ptosis on side opposite to paralysis of extremities and 
face. 

4. Though no obvious affection of iris or recti, yet a 
patient may turn his eyes most readily from the affected 
side, and open the eye widest on the side of the paralysis. 

I must take leave to remark, that it has seemed to 
me of the greatest importance to lay down with all possible 
precision the law of hemiplegia^ inasmuch as, being thus 
a, starting-point, we can reduce the apparently anomalous 
cases to their proper laws. Nor do I think we should 
have remained so long in a state of uncertainty upon 
the diagnosis of nervous affections if we had not taken it 
for granted that their whole nature was to be anomalous. 
There must be as invariable a law for nervous action as for 
any other physical phenomena ; and, if anomalous, it must 
be because our law has not been fairly deduced. 

Whilst I have been thus attempting to prove the certainty 
find definite nature of the law of common hemiplegia, a host 
of cases must have occurred to every one, which seem to be 



CERVICAL PARAPLEGIA HEMIPLEGIA. 149 

exceptions to the rule. My next attempt must, therefore, 
be to show that they belong to quite another law : 

1. The leg is often more affected than the arm. 

2. The seventh may be alone paralysed. 

3. The third nerve is often alone, or to an extreme 
degree affected, and on the same side as the seventh. 

4. The loss of sensation is often very much greater than 
the loss of motion. 

Cervical Paraplegia — Hemiplegia. 

Amongst the exceptions to the ordinary law of hemiplegia 
enunciated above are forced to be considered those in which 
the leg is more affected than the arm, or in which the former, 
contrary to what is usual, does not recover so rapidly as the 
latter. Although I feel that I am not at present in a con- 
dition to explain all these exceptions, yet so many of them 
may be explained, and the conditions here, as elsewhere, 
must stand to each other in such an invariable relation, that 
it may be hoped that such examples as now place them- 
selves conspicuously against our generalisation may serve as 
landmarks pointing to a yet higher law. 

Having once obtained a general expression for a class of 
facts, the mind becomes alive to such as do not run parallel, 
and seeks for modifying circumstances. Thus, having seen 
what is the general condition in hemiplegia, depending 
upon local lesion of the encephalon, if we find cases which 
do not present corresponding phenomena, we cannot refer 
them to the same cause. Exceptional cases to the law of 
local lesion may depend upon hysteria, or an allied condi- 
tion ; also upon complication of encephalic disease with 
disease of the cord ; or arise from disease situated in the 
muscles or nerves of the paralysed member itself. I have 
also seen two cases of hemiplegia in which the arm 
recovered before the leg, in which post-mortem examination 
showed the disease to be at the inferior part of the posterior 
lobe of the cerebrum, neither the corpus striatum nor 
thalamus opticus being implicated. When the seventh 
nerve is alone affected, the causes producing the paralysis 
are for the most part so situated as to implicate the nerve 
in its course, or at its immediate origin. 



150 DISEASES OP THE NERVOUS SYSTEM. 

I have not seen or been able to find tbe records of any 
cases which form exceptions to this. The complicated course 
of the seventh nerve through the bony canals of the 
petrous portion of the temporal bone, and subsequently its 
exposed position on the face, render it very obvious to disease. 

Amongst the exceptions to the ordinary law. of hemiplegia 
none are more common than those of the third nerve. In 
hemispheric lesions of a moderate extent this nerve is rarely 
much affected, yet it is amongst the nerves of the body most 
subject to paralysis. 

Before detailing* the general phenomena of these cases I 
will call your attention to the origin and intercranial course 
and communication of the third pair of nerves, which have 
also been so ably remarked upon by my friend Mr. John 
France, to whom we are indebted for the fullest report of a 
large number of cases of paralysis of the third nerve. 

The nerve has its origin near an extremely vascular 
portion of the brain, the substantia perforata postica ; to 
use Mr. France's own words, " we find the nerve, almost 
throughout its intercranial tract, in the immediate vicinity 
of those which must be regarded as very dangerous allies ; 
first hooking round the posterior cerebral artery to traverse 
the narrow interval between that vessel and the superior 
cerebellar, then running forward nearly parallel to the poste- 
rior communicating artery, then crossing the termination of 
the internal carotid immediately on its outer side, and 
closer to it than any other nerves in the cavernous 
sinus." 

" The sixth nerve, it is true, is previously in actual con- 
tact with the coats of this vessel, but running along the floor 
of the sinus, must in a great degree be secured from pressure, 
as from the upward direction of the current of the blood the 
horizontal portion of the carotid must be rather raised from 
than pressed against the inferior wall of the sinus upon each 
contraction of the left ventricle, and from the same cause 
the inferior wall of the artery itself must be mechanically 
the least liable to morbid distension or rupture ; that nerve, 
however, sometimes suffers like the third." 

But not only has the third nerve these dangerous allies in 
its course, but, from its position and the gravitating tendency 



CEEVICAL PARAPLEGIA — HEMIPLEGIA. 151 

of subarachnoid effusions, it is most subject to be pressed 
upon in its course by inflammatory effusion. 

Also, near its entrance into the orbit, it is joined by 
branches of the sympathetic from the cavernous ganglion, 
and by a branch of the fifth, which extensive nervous com- 
munication explains the functional or sympathetic affections 
of this nerve. 

Double vision is a common effect of paralysis of the third 
nerve, which, if unexplained, might lead to the supposition 
that the central sensory ganglia were implicated ; but in 
these cases the diplopia arises from the want of consensual 
action of the recti muscles of the two eyes, so that they 
cannot be brought to adapt themselves to the same object ; 
and hence, as Mr. France has remarked, we get two forms 
of diplopia, '* one arising from disagreement of the 'planes of 
the optic axes, as when an object is held towards the faulty 
side, but above or below the level of the eyes, one only of 
which can be raised or depressed; the other from defect 
of convergence of the axes, as when an object is presented on 
the level of the eyes, but on the sound side, towards which 
the affected eye cannot follow it." 

In many cases of paralytic affection of the third, as shown 
by ptosis of one of the eyelids, we cannot suppose that any 
central organic disease exists. The class of patients in which 
they occur, and the rapidity of the cure, the nature of the 
means which are known from experience to be most success- 
ful, together with the complete localisation of the affection, 
justify this opinion. 

The cases of ptosis recorded by Mr. France, in the Guy's 
Hospital Eeports, illustrate the general history of these cases 
very well. The remarks given above, upon the intimate 
connection between this nerve and the large venous sinus and 
the arterial trunks, together with the the tendency of mem- 
branous inflammation to occur at the base of the brain, and 
for effusions to gravitate there, will serve to elucidate much 
of the obscurity of their pathology. I shall here quote two 
or three cases given by Mr. France : 

George D — , set. 12, who had in infancy suffered from hydrocephalus, 
and possessed a somewhat disproportionately large head, presented himself at 
the Eye Infirmary of Guy's Hospital on February 7th, 1845. He was 



152 DISEASES OF THE NEEVOUS SYSTEM. 

subject to frequent attacks of pain in the head, particularly just over the 
left eye, and sometimes at the corresponding point on the opposite side, and 
to frightful dreams, disturbing his sleep, and causing him to scream 
violently. AVhen most troubled with headache, often two or three times a 
week, he had sickness and vomiting, apparently unconnected with errors in 
diet. His general aspect was indicative of debility ; he was sallow, but in 
a manner intelligent and lively. Nine days before application he was 
seized with headache and vomiting, which lasted together with frequent 
twitching of the left eyelid, for a couple of days, when the lid dropped, and 
he became unable to elevate it without the assistance of the hand. Upon 
the patient's application, ptosis was complete, but he could slightly raise the 
lid on wrinkling the forehead by the action of the occipito-f rontalis. Abduc- 
tion of the affected eye was well performed ; the eye then slowly returning 
towards, but not quite reaching the centre. Adduction, elevation, and 
depression, more especially the two latter, were impracticable. The pupil, 
examined separately, was active, but inclined to remain rather more dilated 
in the dusk than the opposite pupil. The sight of either eye was good 
when both were employed ; double vision resulted, unless the objects were 
held to the temporal side of left eye, so as to permit the axes to correspond. 

The boy was put under the influence of mercury sufficiently to redden the 
gums, and repeatedly blistered, and was discharged with restored power over 
the globe and palpebra, after about seven weeks. 

Henry H — , set. 26, a fishmonger, subject to occasional bilious derange- 
ment, and, in hot weather, to pain across the forehead, for the relief of 
which he had habitually employed leeches with benefit. He was, six weeks 
before application at Guy's, suddenly seized, immediately after a walk of six 
miles, with severe pain in the head, tinnitus, vertigo, and sickness. He had 
not partaken of anything likely to disorder the stomach. The sickness, 
however, accompanied with the other cerebral symptoms just mentioned, 
and with loss of power of elevating the upper lid on the right side (which 
took place suddenly on the first onset of these symptoms), continued for 
three or four days. He was twice cupped, was blistered at the nape of the 
neck, and had purgative medicine administered ; and under these remedies 
the sickness subsided, and the power of the levator palpebrse was in some 
degree restored. On application at the hospital, November loth, 1845, he 
still complained of headache and vertigo ; the right upper eyelid could only 
be raised so far as to uncover about a third of the pupil, unless the occipito- 
frontalis was called into action ; the movements of elevation, depression, and 
adduction of the globe were much limited, and the globe when quiescent 
maintained the position of abduction. There was diplopia in regarding any 
object to the left of the median line, and the right pupil, which the patient 
spontaneously described to have been at first much larger than the left, was 
still a trifle more dilated and sluggish than the latter, which was of medium 
size and active. He was ordered compound calomel pill, and two grains 
sulphate of zinc with the compound infusion of roses and. salts, three times 
daily, and a blister to the back of the neck. 

November 21st. — Though convalescing, the patient still complained of 
occasional vertigo and headache in the morning ; he could raise the right 



CEK^ICAL PARAPLEGIA HEMIPLEGIA. 153 

nearly as well as the left superior palpebra, the motions of the globe were 
almost perfectly restored ; horizontal diplopia had ceased, there yet remained 
a trifling increase in size and indolence in action of the pupil. A grain of 
quinine was added to each dose of his mixture, two of the daily pills having 
been previously discontinued. 

28th. — He was nearly well. A just perceptible difference existed between 
the degree of elevation of the two superior palpebrae ; the power of adducting 
the right globe was perfect ; that of elevating and depressing it still 
restricted within less than the natural boundaries ; hence, double vision 
which had ceased a week before in the horizontal direction, was still mani- 
fested at the extremes of the perpendicular movements of the eyes. Some 
indolence was the only remaining morbid affection of the pupils. 

John C — , set. 28, a gas-work labourer, usually in the enjoyment of 
excellent health, who had abstained from indulgence in liquor, and been 
exempt from exposure to the furnace for some time before his application at 
the hospital, September 29th, 1845, """^s attacked about two months 
previously with cephalalgia, vertigo, and double vision, which were not 
preceded by any irregularity in diet, and subsided without treatment in a 
couple of days. For eight or nine days before he applied at Guy's he 
suffered from severe pain at the occiput, extending along the right side of 
the head, occurring chiefly in the night and on his rising from bed in the 
morning, and lasting for two or three hours at a time. This was followed 
by vertigo and diplopia, and shortly after by dropping of the right upper 
eyelid. 

When he came for advice he was free from pain, and unconscious of any 
other ailment than complete inability to raise the lid, though he could 
slightly separate it from the inferior palpebra by wrinkling the forehead by 
the occipito-frontal muscle. The position of the globe, when at rest, was 
with the cornea directed straight foi-wards. The patient could abduct the 
globe freely, and adduct it too, as far as the centre ; he could also elevate 
and depress the globe, but within very narrow limits only, whence objects 
held at all to the left side of the median line, or much below or above the 
level of the eye, were perceived as double. The pupil of the right eye was 
of thrice the diameter of the left, but acted conjointly with it ; and also, to 
a slight extent, independently : the left eye was unaffected, and no other 
paralysis existed. He was ordered cupping to ten ounces, and a purgative 
at once— two grains of calomel with one of opium three times daily ; chalk 
mixture if necessary, and the stronger mercurial ointment for inunction on 
the temple. 

Under this treatment he rapidly improved. At the expiration of a week 
he could raise the lid so as to expose three fourths of the pupil ; he could 
adduct the cornea considerably past the central point, and raise and depress 
it more extensively. Double vision of objects on the left continued, and the 
pupil was equally dilated, but perhaps more active. The mouth was 
becoming sore. In another week the motions of the lid and eye were almost 
entirely recovered ; the pupil was reduced to two thirds of its late habitual 
size, and had regained its briskness of movement, and the patient shortly 
after discontinued his attendance at the infirmary. 



154 DISEASES OP THE NEEVOUS SYSTEM. 

A very rare cause of paralysis of the third may be aneurism 
of one of the arteries lying near it in its intercranial course. 
Such a case occurred under my own observation, and is 
recorded also by Mr. France. The following is an abstract 
of the case : Sarah S — , ast. 20, a stout and short-necked 
girl, of a plethoric habit, and subject to constipation, stated 
that for a month she had suffered from headache and giddi- 
ness whilst sitting at needlework, and that five days before 
admission she was suddenly seized with pain over the right 
eyebrow, faintness, and vomiting. Leeches were applied with 
relief, but the next morning the right upper lid was dropped, 
and vision of the same side impaired. She had, on admis- 
sion, been bled, leeched, and purged, notwithstanding which 
the fall of the lid and impairment of vision had both increased. 
Seven days after coming into the hospital, she retired to bed 
complaining of headache, from which she had not, while in 
the hospital, been quite free. She slept comfortably until 
five o'clock in the morning, when the nurse's attention was 
attracted by her moaning. She was then found in a state 
of insensibility, without convulsion, deep low stertor, and froth 
at the mouth and nose. 

On a post-mortem examination there was found consider- 
able recent extravasation of blood at the base of the brain, 
penetrating extensively into the meshes of the pia mater 
between the convolutions. The haemorrhage had taken place 
from the bursting of a small aneurism situated on the pos- 
terior communicating artery of the right side, and which had 
produced compression of the right third nerve. 

The communications of the third nerve with the fifth and 
sympathetic, may explain the apparently functional chai-acter 
of many of its affections. Many persons in whom they occur 
are weak and debilitated subjects, with obvious disorder of 
the general health, and are relived by alteratives, purgatives, 
and tonics. M. Marchal has given, in the ' Archives 
generales ' (tome xi), a memoir on paralysis of the third 
pair of nerves following upon neuralgia of the fifth pair. 
He believes that in many cases the lesion of the third is 
subsequent to a retrograde action, propagating itself from 
a few filaments of the fifth, and he gives his opinion that the 
course of such influence is through the lenticular ganglion. 



. CERVICAL PARAPLEGIA HEMIPLEGIA. 155 

It is well known that irritations of the fifth from diseased 
teeth, or a blow, may cause amaurosis, but yet it may be 
doubtful whether the cases recorded by Marchal in support of 
his opinion be correct ; whether the anaesthesia of the fifth 
nerve, and the supervening paralysis of the third, are not 
results of a common cause, having its seat in the membranes, 
and affecting these nerves in their intercranial course. It 
is sufficient, however, for the main argument of this lecture 
that they do not invalidate the law of hemiplegia, inasmuch 
as they belong to an entirely different series of disorders. 
Whether membranous or sympathetic, I have not now the 
time to discuss, but they have certainly not a hemispheric 
origin. 

The most remarkable exceptions to the law of hemispheric 
lesion present themselves to us in the affection of the nerves 
of sensation, and I particularly direct attention thereto. 

First. — Because they bear upon the question of the exist- 
ence of separate centres in the brain for common sensation 
and voluntary motion. 

Secondly. — In reference to the pathology of these cases ; 
because I think one class of them, at least, is strictly func- 
tional. 

Without entering upon a discussion of the seat of sensa- 
tion, or where the sensorium commune is situated, I Avould 
call attention to several conditions under which anassthesia 
occurs. 

First. — Anaesthesia is produced by diseases of the blood. 
Ether, chloroform, Bright's disease, and gout supply us with 
examples. 

Secondly. — Anaesthesia is said to arise from mental states, 
as in mesmerism. It certainly may be produced by nervous 
exhaustion, by a shock, and often exists in hysteria. 

(a) It accompanies the shock of apoplexy, but is generally 
not persistent. (b) It may form a part of the phenomena of 
epilepsy. (c) It may follow venereal excesses, over-study, 
and liver derangements. 

Thirdly. — Anaesthesia forms a prominent symptom in one 
form of paraplegia. 

Fourthly. — Anaesthesia may be an affection of the peri- 
pheral nerves. 



156 DISEASES OF THE NERVOUS SYSTEM. 

I know of no cases of anasstliesia unaccompanied by loss 
of motion which arise from local disease of the encephalic 
centres. 

My first assertion that anaesthesia may be the result of 
blood diseases, requires no very difiicult train of facts to 
substantiate it. 

My attention was fii'st called to the peculiarity of these 
cases by the following. The error I then made in diagnosis 
has been of the greatest service to me as pointing to a 
different pathology of these cases from that which would 
refer them to local central lesion. 

In April, 1843, ^ male patient, set. 35, was admitted under Dr. Addison 
into Guy's with the following history and symptoms : — He is by trade a 
painter, lives but poorly, and says he drinks nothing but water. In the 
pursuit of his vocation he is compelled to take long journeys, and to remain 
for many hours standing to paint. Yesterday morning (the report says), 
when at work, he fell from the steps on which he was standing, quite 
insensible to the ground, but he soon recovered his consciousness, and found 
that he had complete anassthesia in the right half of his body, including the 
integuments of the forehead and face. 

After being in the hospital a short time he was found in a drowsy state, 
and when roused seemed confused. The pupils were natural. There was 
some muscular weakness and awkwardness in the right side. He has a very 
vacant look. Pulse 75. Hypertrophy of left ventricle; urine highly 
coagulable; sp. gr. 1018; small in quantity. During the course of five 
weeks the sensation returned to the parts affected, but with fluctuations 
About the 18th of June, that is two months from the attack, he was 
suddenly seized with all the severe symptoms of renal catarrh with pleurisy, 
and died the next day. 

Dr. Addison, under whose care, as I have said, the case occurred, had 
prepared me for a disappointment in my anticipations of local lesion ; yet, 
from the suddenness of the attack, and the complete hemiplegic character of 
the malady, I must confess I should have been a disbeliever had we had no 
post-mortem examination. I wrote in my note-book at the time, a series of 
reasons why there should be, and why there should not be, any local disease. 

The brain was anjemic ; no lesion, nor traces of one, could be detected, 
although it was carefully sliced throughout. The tissue was of the 
normal consistence. No local ramoUissement nor effusion existed. The 
heart was hypertrophied. Aorta healthy; large vessels good. Kidneys 
contracted, granular, mottled, firm, with some serous cysts on the surface. 

Modern discovery has supplied us with abundant proof of 
the ana3sthesic effects of blood diseases in the phenomena 
produced by the inhalation of ether and chloroform. Nor 



CERVICAL PARAPLEGIA HEMIPLEGIA, 157 

are we^ I think, surprised that a patient should be able to 
move his limbs, to converse and direct his eyes to various 
objects, to be to a considerable extent conscious ; and yet 
that he should be quite unaware of the operations of the 
surgeon on the extremities at this same time : when we 
take into consideration the extreme extent of nervous distri- 
bution in the tissues, that the ether is permeating all these, 
and that the skin, from its rich supply, must be largely 
affected : whilst, as I have often seen by experiment on this 
subject, muscular contractility is not affected by the circu- 
lation of ether, nor even by immersion in it. It is however 
probable, that there is, with these diseased conditions of the 
blood, some modification of nutrition. 

The second class of cases in which anaesthesia preponder- 
ates over loss of motion are probably functional, I mean 
esseyitially nervous, restricted to the nerves, not caused by a 
hypersemia, nor a local determination of blood, nor a conges- 
tion of the blood-vessels, nor by impurity of the blood. 

A nerve has its aptitude to perform its function in virtue 
of its proper organisation, as muscle is contractile as the 
result of its physical constitution. 

A nerve in action, is probably undergoing a moi-e rapid 
change in its organisation than a passive nerve ; but, inde- 
pendent of this, we must admit, that there is strictly func- 
tional activity ; for, whilst a nerve conducts the mandates of 
the will, or receives impressions from without, it is in action 
through all its length and breadth, yet we cannot admit 
that its entire organisation is changed. Perhaps the con- 
ducting wire of a battery may serve to convey my meaning. 
When it connects the two ends of the series, it is still a 
copper wire, but it has anew function — it is magnetic. The 
current does not change it organically, though it does func- 
tionally ; yet the current is apt, in time, to affect its organ- 
isation. Thus the heat induced, renders it more exposed to 
oxidation ; and, if the wire be of a substance quickly to 
oxidate, its consequent organic change would be quicker. 
But, without taking up your time with such speculations, it 
will, I think, be admitted, that the present class of cases are 
functional, and that to view them in any other way is apt to 
lead to dangerous practice. 



158 DISEASES OF THE NERVOUS SYSTEM. 

About two years since, I was one evening called in great 
haste to a gentleman well known to me. He is of thin, 
spare frame, about five feet six inches in height, active and 
very excitable, nervous, has a multiplicity of duties to 
perform, and no repose in his disposition. It was about 
half-past seven in the evening, he told me, in great agita- 
tion, that he had lost the use of his right leg and arm, but 
on investigation I found he could forcibly thi-ow forward the 
leg or the arm, but there was an awkwardness in directing 
their movements ; the most prominent feature in his case 
being the anaesthesia ; the awkwardness seeming to be the 
result of diminished sensation, so that he could not tell the 
whereabouts of the limb, rather than to arise from loss of 
power. This being totally opposed to the law of hemiplegia, 
I was disposed to regard it as functional, the result of 
nervous exhaustion, and prescribed nothing but a long and 
sound sleep. The following morning he was well. 

A gentleman, recently married and overwrought by 
mental exercise, complained to me that he had just been 
seized with numbness of the right leg, and that on attempt- 
ing to walk he found his gait very awkward, and he feared 
he was going to have an attack of paralysis. On inquiring, 
I found that the want of power over the muscles arose from 
the numbness, rather than from any absolute want of mus- 
cular power, and was an awkwardness rather than paralysis. 
Using as we do our muscles under the direction of sensation, 
this will be readily understood. Knowing his general con- 
dition, I advised vacuity, sleep, and a tonic, and all his 
symptoms soon disappeared. 

It would occupy more than the whole time allotted to 
these lectures to point out the strange vagaries of sensa- 
tion manifested in these cases, and the apparent paralyses 
that accompany them. The object I have is to show that 
where the loss of sensation and its various modifications are 
so great, with much affection of the muscular power, and 
often in no other way than I have described above, the 
disease does not arise from central lesion of a local Tcind, and 
that these cases are not exceptions to the law of hemiplegia 
already defined, but come under quite a distinct one. The 
remedies approved of by experience warrant such a conclu- 



CERVICAL PARAPLEGIA — HEMIPLEGIA. 159 

sion, such as vacuity from business, sleep, mild nourishment, 
moderate purgation, and good air and exercise. Congestion 
may occur, but never admits more than gentle local de- 
pletion. 

I have known one case in which the strange vagaries of 
sensation would not let the patient sleep, for just as con- 
sciousness was lost a strange creeping came over the scalp 
and woke him ; this was so continued, and so certain, as at 
last to reduce the patient sadly. It was obviated by his 
wife watching him, and as he fell off she gently passed her 
hand over the head, and the pressure so produced on the 
nerves drove away the subjective sensations, and he slept. 

Of the state induced by mental impressions, or from 
nervous exhaustion, induced by monotonous movements or 
otherwise, called mesmeric, I have no experience, and cannot, 
therefore, give any opinion thereon. 

I would, however, place in this category of anaesthetic 
affections those strange cases of apoplexy in which there is 
paralysis of one side of the body and antesthesia of the 
other, the paralysis depending upon lesion of the hemisphere, 
and following the law of hemiplegic paralysis, the anaes- 
thesia occurring without any lesion in the hemisphere which 
corresponds to these parts, and is functional after the same 
manner that we get convulsions on the side which is not 
paralysed, the result of the shock of the injury on the other 
hemisphere. We cannot, therefore, regard it as the effect 
of a local lesion, nor an exception to the hemiplegic law, 
nor any evidence of separate centres for sensation and 
motion. 

A tingling, a transient numbness, a feeling of coldness, a 
creeping, or something equally trifling and transient may 
precede severe and often sudden disorganising processes, 
and yet, strange to say, as the well-marked paralytic effects 
are produced by the lesion, the affection of the sensation 
shall fade away. They have been like the cloud before the 
storm — it is now passed ; the oak is riven, but the sun still 
shines. These angesthetic phenomena are thus the signs of 
deranged function, which, we know, often precede greater 
changes. Abercrombie gives the case of a young lady, who 
for two or three years suffered from transient hemiplegic 



160 DISEASES OF THE NERVOUS SYSTEM. 

anaesthesia ; this functional disturbance foreshadowing the 
ramollissement which, at the end of this time, came on. 
There are on record many cases, said to be anomalous, in 
which the sensation of parts has been much diminished or 
permanently lost. 

I quoted some of these in my last in speaking of peri- 
pheral paraplegia, in which the morbid impression seemed 
to have commenced in the integuments from cold, or from 
some inexplicable cause, as in those remarkable examples 
occurring during the epidemic in Paris. I think if the 
cases, whose general details are shown by the following 
examples, be viewed in connection with those of peripheral 
paraplegia, we shall not find them anomalous, but have to 
refer them to the cases of peripheral disease. 

Dr. Yelloly, in the third volume of ' Medico-Chirurgical 
Transactions,' gives a case of anassthesia which strikingly 
exemplifies this view. It occurred in a man aged fifty-eight, 
a Scotchman, after being much fatigued and heated in his 
attendance as one of the grand jury in Kingston, in Jamaica, 
in very sultry weather, he went to bed with the window 
open. On awakening in the morning he found his feet and 
ankles perfectly numb, but without pain, and without the 
muscular power being at all affected. Soon afterwards he 
felt a numbness, with a tingling pain in his little finger, 
such as occurs in a part asleep, and by degrees finger after 
finger became affected until both hands were to a great 
degree insensible. No head symptoms, nor any affection 
of his general health nor viscera. A physician of eminence 
attributed the disorder to scurvy ; but he had no cuticular 
affection until twelve months after the occurrence of the 
numbness, when some red pimples showed themselves on his 
legs on his lying down on the ground after walking up a 
steep hill. The hands up to the wrist, and the feet half- 
way up the leg, were perfectly insensible to any species of 
injury, as cutting, pinching, or burning ; the insensibility 
did not suddenly terminate, but it existed to a certain 
degree neai-ly up to the elbow, and for some distance above 
the knee. 

His hands were of a somewhat purple hue. If he wished 
to ascertain the temperature of anything, he was under the 






CERVICAL PARAPLEGIA — HEMIPLEGIA. 161 

necessity of putting it to his face or neck, or upper part of 
his arm. His skin seemed to be unusually affected by heat. 
His hands were never free from blisters, which he could get 
by inadvertently placing them too near the fire. 

The power of motion existed in the muscles of both hands 
and feet. He could grasp pretty firmly, but in holding 
anything he was apt to drop it if his attention was at all 
called away. The susceptibility of impressions generally, 
as well as the muscular power, seemed to be diminished. 

The result of the case is no further given than that the 
patient was not benefited by the treatment. He left England 
again for the West Indies. I cannot but regard this as the 
result of injury to the cutaneous nerves, arising, in the first 
instance, from exposure whilst heated. 

In enumerating the apparent inconsistencies of anaesthesia, 
Abercrombie says that a gentleman who was under the care 
of the late Dr. Hey, of Edinburgh, had two paralytic attacks 
at the distance of eight months from each other. In the 
first there was perfect loss of feeling with only partial loss 
of motion ; in the second there was perfect loss of motion 
with only partial loss of feeling. He recovered perfectly 
from the first attack after a short time ; but after the 
second, though he recovered partially, he continued to drag 
his leg, and, after a year or more, died of apoplexy. The 
different results of the two attacks precisely agree with the 
principle I have been endeavouring to establish. I believe 
there is yet a source of many functional diseases of the 
nervous centres which, in modern medicine, has been too 
much neglected. I refer to the interweaving of the sym- 
pathetic with the nerves, and, as we have reason to believe, 
entering into connection with the nervous centres them- 
selves. States of the brain produce functional disorders of 
the stomach and liver, and these in their turn produce 
strange nervous conditions ; amongst the most important of 
which to be here named are numbness of the fingers or 
face, pain over the eyebrow and on the occiput, partial 
paralysis of the retina, giving rise to hemiopia or indistinct- 
ness of vision, with vertigo, all of which often vanish at 
once by good exercise or an active purgative. Although 
this attempt to generalise and classify nervous affections is 

11 



162 DISEASES OP THE NEEVOUS SYSTEM. 

necessarily very defective, yet should it hereafter be found 
that a careful attention to the degree in which sensation is 
affected in relation to paralysis may serve to inform us 
whether the disease be local or general, functional or 
organic, as indeed I think it will, the object of these lectures 
will have been attained. 



CASES OP PAEAPLEGIA. 



Paraplegia prom Tumours compressing the Cord. 

Tumours growing in the cord, or from its membranes, are 
among tbe more rare causes of paraplegia. With the ex- 
ception of scrofulous deposits, these formations are most 
frequently seated in the loose tissue under the visceral layer 
of the arachnoid, or grow from the inner surface of the dura 
mater. They have generally been regarded as malignant, 
but their microscopical characters, their indisposition to 
invade or infiltrate surrounding parts, and their non-occur- 
rence simultaneously in other organs, refer them to a simpler 
class of tumours, the jibro-nuclear or Jibro -cellular. The 
cord and its membranes appear to be extremely rarely 
affected primarily by cancerous growths. When malignant 
disease attacks these parts it is generally by secondary 
diffusion, or by extension from the bones or other structures 
adjacent. 

In paraplegia from compression of the cord by tumours, 
pain is, with but rare exceptions, a prominent and charac- 
teristic symptom. Some writers have expressed an opinion 
that it is present only when the membranes or surrounding 
structures are implicated, and not when the disease is 
strictly limited to the cord itself. This does not appear to 
be a well-founded distinction. In a case recorded by 
Mr. Shaw, in the ' Transactions of the Pathological Society ' 
(1848— g), paraplegia was produced by two scrofulous 
tubercles occupying the interior and lower part of the spinal 
marrow, and invested all round hy a thin layer of medullary 
^ Eeprinted from the ' Guy's Hospital Eeports,' 1856, p. 143. 



164 DISEASES OF THE NERVOUS SYSTEM. 

matter ; yet the patient complained so much of pain in the 
lumbar region that it was thought her symptoms might arise 
from caries of the vertebras. After death the membranes 
and bones were found healthy. The character of the pain 
appears to be very variable. In one case, quoted by Aber- 
crombie, the first symptom was neuralgic pain in the arm, 
which diminished as paralysis came on. In another the 
patient had sciatic pain extending to the toes. Mostly the 
pain is referred to the back, and more or less correctly 
indicates the seat of the disease, from which it radiates in 
the direction of the nerves whose roots are invaded. Where 
there is no actual pain there may yet be other modifications 
of sensation, as coldness, or heat, or sudden alternations of 
these, and many other varieties of impaired feeling. 

Next to pain is the frequency of muscular contractions in 
the affected limbs, followed as the case progresses by flexion 
and rigidity, and attended by a gi-eat susceptibility to the 
excito-motor stimulus. These phenomena are most apparent 
where the cord is merely stretched or compressed, and where 
no other change has occurred in it beyond atrophy, the 
communication with the brain being at the same time not 
entirely destroyed. If there be inflammatory softening of 
the substance of the cord, then these more characteristic 
symptoms may be absent, as they are also in compression of 
the cord from fracture when its structure is bruised and 
softened. Spasmodic contractions of the muscles of the 
extremities occur whether the fibres of the cord are com- 
pressed by tumours on its surface or stretched by tubercle 
deposited within it. At one stage of a case there may be 
rigid extension, which may be gradually followed as the case 
progresses by as rigid flexion, though the muscles at the 
same time may become atrophied and flaccid. 

The vagueness of the early symptoms, in these as in other 
cases of paraplegia, deserves especial consideration in a 
practical point of view. In the first case here recorded, 
the early symptoms, cough and slight dyspnoea, and some 
pain in the back and shoulders, were referred to tubercular 
disease of the lungs. In the second, the spasmodic action 
of the limbs was so great that for a time the case was re- 
garded as one of hysteria. In fine, the symptoms of neu- 



CASES OP PARAPLEGIA. 165 

ralgia, hysteria, lumbago, rheumatism, phthisis, colic, renal 
calculus, pleuritic and hepatic affections, may rise like so 
many phantoms, to delude us at the onset of most paraplegic 
affections, and the errors they are apt to lead to can be 
avoided only by a rigid inquiry. Of the diseases of the 
nervous system in general, and of paraplegia in particular, 
it may be said that there is no symptom or single group of 
symptoms which, taken alone, can serve as a secure basis of 
diagnosis ; the whole particulars included in the clinical 
history and present state of the patient must be viewed in 
their relation to each other and to time, before we can dis- 
cern the truth they indicate. 

Case i. — Paraplegia. — Tumour growing from the inner surface of the 
dura mater of the cord. Early symptoms, simulating incipient 
phthisis ; subsequently rheum,atis'in. 

Francis H — , jet. 30, a married man of temperate habits, by trade a baker ; 
admitted into Guy's Hospital January 30th, 1850, with symptoms supposed 
to be due to incipient phthisis. He had had cough and shortness of breath 
for two months, lost strength and flesh rapidly, and had frequent perspira- 
tions. The cough was accompanied by pain in the upper part of the back 
and in the right shoulder, but the complaint he made of it was not such as 
particularly to arrest attention. The heart's action was normal ; respiration 
24. He was ordered to take cod-liver oil. There was nothing specially 
noticed in his symptoms until the 4th of February, when he suddenly found 
himself unable to empty his bladder ; he was relieved by the catheter, and 
was not for some time again troubled in that way. A week subsequently the 
report says, " He is improving under the use of the oil." On the 20th the 
pain in the right shoulder became much more severe, and he complained of 
feeling very languid, though up to this date he was able to walk about a 
good part of each day. He had occasional rigors and profuse sweatings. 
The increase of his symptoms at this time was attributed to his having taken 
cold. The next day the knees were painful, and the legs weak, he could 
not support himself, though he had the power of moving freely in bed. 
The character of the affection of the joints was such as to induce the belief 
that he was now labouring under rheumatism, and he was treated accord- 
ingly, apparently with good effect. At this time the inability to pass water 
returned, and decided symptoms of paraplegia came on, with impairment of 
sensation as high as a line round the chest, corresponding to the third rib ; 
the boundary of the ansesthesia was not, however, sharp and defined. The 
arms were slightly enfeebled. The paralysis of motion in the lower extremi- 
ties and sphincters became complete, but he retained the power of distin- 
guishing the seat and direction of superficial impressions on the skin, though 
no amount of pinching or pricking gave rise to pain. The spinal column 
was straight, and no tender spot could be discovered on percussion, nor by the 



166 DISEASES OF THE NERVOUS SYSTEM. 

application of a hot sponge. On the 9th of March the urine was ammoniacal 
and contained blood. The rigors continued, and he had constant and profuse 
sweatings. A large slough formed over the sacrum. The pulse became 
frequent and feeble. He died rather suddenly on the 22nd, about four 
months from the date of his first symptoms. 

Sectio cadaveris. — Cord softened to the extent of three quarters of an inch 
opposite the first dorsal vertebra. A careful examination of a transverse 
section showed the softening to be general, the anterior parts not being appa- 
rently more affected than the posterior. The softening seemed to be due to 
diminished nutrition from pressure, no traces of inflammatory exudation 
being detected by the microscope. The arachnoid was healthy. Attached 
to the inner and anterior surface of the dura mater, opposite the softened 
portion of the cord, was a small tumour of the size of a hazel nut. It was 
vascular, and consisted of nucleated cells and free nuclei in a slimy, albumi- 
nous blastema. An in-egular cyst existed in the centre of the mass. The 
bones and ligaments of the cord were healthy. The bases of both lungs were 
consolidated by pneumonia of recent date ; there was no trace of chronic 
disease. Liver soft ; tissue injected. Urethra healthj\ Four false passages 
into the bladder. The pelves of both kidneys and the bladder full of a 
bloody purulent secretion. The mucous membrane dark and sloughy. The 
secreting portion of the kidneys variegated with spots, and irregular lines of 
pus in the suppurating tubules. 

Remarhs. — An inspection of the chest movements^ even in 
an early stage, and before the more decided symptoms of 
paraplegia came on, would doubtless in this case have eluci- 
dated the cause of the dyspnoea and cough. In a similar 
case which came under my notice, the patient was supposed 
to be labouring under ordinary bronchitis with dyspnoea, 
when I was requested to see her ; but there the partially 
paralysed movements were at once obvious when the chest 
was exposed. I have to record another case, one of indura- 
tion of the cord, where the early symptoms were referred to 
the chest, and supposed to be phthisical. The difficulty of 
detecting diffused miliary tubercles with the stethoscope, and 
the possibility of their existing without producing any per- 
ceptible dulness or marked flattening of the chest, favoured 
the erroneous inference of phthisis which was drawn in these 
cases from the cough, emaciation, and perspiration. The 
suspicion of such a fallacy, with a scrutiny of the thoracic 
movements which I have hinted at, would guard against a 
similar error. The cough of hysterical subjects, which is 
often accompanied with tenderness in the upper pai't of the 
dorsal region of the spine, may receive some elucidation 



CASES OF PARAPLEGIA. 167 

from the early symptoms in this case. That the cough and 
dyspnoea had here a spinal origin seems evident^ although 
doubtless, in the progress of the case^ the impeded respir- 
atory movements, and the consequent congestion of the 
lungs, had a great share in increasing the symptoms. The 
rigors and sweatings which characterised the middle period 
of the case were probably due to the secondary morbid 
changes in or about the urinary passages set up by the 
retention of urine and the injuries from catheterism, and not 
to stretching or compression of the structures of the cord 
by the tumour ; at least it is noticeable that they were sub- 
sequent to the first catheterism, and in most cases they seem 
to be owing to secondary lesions. I shall not now venture 
to call the growth found in this case malignant, although at 
the time I examined it I had no doubt that such was its 
nature, and similar growths are so described by authors. I 
have reason to think that, before we pronounce so categoric- 
ally on these productions, we must know more of the indi- 
vidual pathology of the membranes of the brain and cord. 
There was no trace of a repetition of the disease elsewhere, 
as commonly occurs in cancer. This fact, together with the 
frequency of such tumours in the dorsal region, where the 
effects of mechanical injuries are most felt, and the age of 
the patient, render it probable that it was, as its micro- 
scopical structure indicated, a simple growth due to some 
local cause of irritation. In a series of cases we may notice 
the gradations from nuclear and cellular towards fibroid, 
fibrous, and bony, in the character of these productions, 
such varieties being probably due to the rapidity and seat 
of the formation. In this case the structure was such as 
indicated rather rapid growth, and the history of the sym- 
ptoms corresponded to it, ranging over a period of about 
foiir months. In a parallel case of tumour from the theca 
vertebralis producing paraplegia, recorded in the ' Transac- 
tions of the Pathological Society' (1847-8), the symptoms 
had a course of five years, and there the structure of the 
tumour was of a firm consistence ; — osseous where it sprang 
from the dura mater, and at the other parts fibrosis, with 
rough granular matter intermixed. With respect to treat- 
ment little is to be said. A better pathology and a more 



168 DISEASES OF THE NERVOUS SYSTEM. 

correct diagnosis will lead to better if not to more successful 
methods. At present there are no cases where treatment is 
more loosely tentative and empirical than in cases of para- 
plegia where the causes are obscure. 

Case 2. — Paraplegia. — Fibro-nuclear tumour (fibro-plastic) growing from 
the inner surface of the dura mater of the cord, opposite the third 
dorsal vertebra. Bones and ligaments healthy. (See Plate I, fig. i.) 

Sarah A — , fet. 43, was admitted into Guy's Hospital July, 1855, under 
the care of my colleague, Dr. Hughes (whose kindness I have to acknowledge 
in allowing me to make use of this ease). She was a healthy-looking woman, 
of a fair complexion, rather below the middle stature, employed as a domestic 
servant. In January she first felt pains in the shoulders, chest, and sides, 
aggravated at night, and at the time vaguely attributed to cold. She applied 
as an out-patient at a dispensary, and was repeatedly blistered between the 
shoulders without benefit. Her strength failing, she went into the country 
and kept her bed for a fortnight, hoping to obtain relief by rest. Her 
symptoms gradually increased in intensity, and she now began to suffer from 
spasmodic contractions of both lower extremities, but especially of the left. 
After a short time the legs were permanently drawn up to the abdomen ; 
and, according to her description, the cramps and spasms extended to the 
abdominal mi;scles. On admission the legs were flexed, with the heels to 
the nates, nor could they be extended without considerable force. Left to 
themselves after extension, they were suddenly jerked, or more slowly drawn 
up into their former position. No affection of sensation. General health 
good. Respiratory and cardiac sounds normal. Catamenia regular. No 
incontinence of urine, but difficulty in voiding it ; the secretion normal in 
appearance, and acid. Constipation. Tongue clean. Appetite good. Great 
distress, especially at night, from the spasmodic contractions of the legs and 
abdominal muscles. Her sex, her healthy aspect, the absence of any defor- 
mity of the spine, and the spasmodic character of the symptoms, led to the 
suspicion that there was spinal imtation of an hysterical or functional 
character, rather than organic disease. Three days after admission she had 
retention of urine. On the ist of Augiist menstruation returned normally. 
Her general health appeared unaffected. She still made great complaint of 
restless nights from the spasms in her legs, and of a burning pain between 
the shoulders, extending round to the abdomen. The sensibility of the lower 
extremities was unaffected. On the 6th she was cupped over the spine 
without relief. The legs were permanently drawn up to the nates. The 
urine dribbled slowly away. After a few days bedsores began to form over 
the sacrum, and the urine became ammoniacal and loaded with mucus and 
pus. On the 24th she had constant vomiting, and the tongue became dry. 
The spasms in the lower extremities decreased, but the great and incessant 
pain in the back, and the burning pain in the abdomen, prevented her 
getting any rest. Her strength gradually declined ; very extensive sloughs 
formed over the sacrum and hips, exposing the bones beneath to the extent of 



CASES OF PARAPLEGIA. 160 

several inches. She died extremely emaciated on the 15th of Octoher, about 
nine months from the beginning of her symptoms. 

SecHo cadaveris. — Bones and ligaments of the spine healthy. The theca 
vertebralis much distended with fluid. In the dorsal region it was translu- 
cent, and speckled with granular opacities on its posterior surface. Opposite 
the second and third dorsal vertebrae the cord was pushed backwards, and 
compressed and flattened by a smooth oval tumour growing from the inner 
surface of the anterior layer of the duia mater. The tumour had much the 
appearance, and was about the size, of a child's testicle. It had not invaded 
the textures, nor caused any absorption of the anterior columns. These were 
somewhat softened, and separated by the widening of the anterior fissure, 
but still everywhere continuous. Above and below the seat of compression, 
the cord, though small, had its natural firmness and form, and the tubules 
of the roots of the nerves and of the columns, examined microscopically, were 
normal. At the parts softened by pressure, the columns contained granular 
matter and granule cells, scattered amongst the tubules. Over the arach- 
noid, on the posterior surface of tlie cord, there were several scattered fibroid 
plates. The spinal fluid was greatly in excess, but became only very faintly 
opalescent by heat. The structure of the tumour was firm, and consisted 
mostly of cohering nuclei, generally oval, but in the firmer parts linear, 
with a small amount of intervening granular blastema, which in parts had 
become incoi-porated with the nuclei into an obscurely fibrous struc- 
ture. In one or two parts near the surface of the tumour the tex- 
ture was softer, and collections of granular matter and a cell-wall were 
formed around the nuclei. The whole tumour was vascular, and on com- 
pression gave out a slight quantity of clear moisture, but no opaque juice as 
in cancerous formations. The lungs, heart, liver, and intestines were 
healthy, but wasted. Kidneys not enlarged ; their tunics slightly adherent ; 
the surface granular, with a few obscure points of commencing suppuration 
in the tubules. The mucous membrane of the pelves and bladder injected, 
and covered with puriform exudation. The walls of the bladder thick. 
The lesion of the urinary organs was very moderate in comparison with the 
very extensive sloughing about the nates and trochanters. The mucous 
membrane of the rectum was covered with muco-purulent exudation, but 
otherwise healthy. 

Remarhs. — The prominent symptoms in this case, after 
the pain in the back and shoulders, were the painful cramps 
and spasmodic contractions in the lower extremities and 
abdomen. In a case of a similar tumour compressing the 
lower part of the cord, in a young woman whose case is 
quoted by Abercrombie from Gendrin, the patient suifered 
acute pain in both legs, and convulsive retraction of the 
toes, and the sensibility of the left foot was so exalted that 
the slightest touch produced a sense of laceration. It 
appears that the cord, when encroached upon by a tumour 



170 DISEASES OF THE NEEVOUS SYSTEM. 

which lightly stretches or compresses it, reacts as a nerve 
does ; if the disturbance of the structure be but moderate, 
there is spasm and neuralgia, passing on, with increase of 
the lesion, into paralysis and ana?sthesia. Those who hold 
the theory that a motor function attaches to the anterior 
columns, and a sensitive function to the posterior columns, 
will find, to some extent, a confirmation of their views in 
this case, in which the lesion of the anterior columns was 
attended by an early and marked disturbance of the motor 
functions. The symptoms do not, however, seem to admit 
of so limited an explanation. In 1848 I took occasion, in 
some lectures then published, to show that we had no 
clinical facts which, fairly looked at, could be so inter- 
preted ; but that, in disease of the cord not implicating the 
trunks of the nerves or their roots, the motor function 
generally suifers first, whether the lesion be in the anterior, 
the posterior, or the lateral columns. My further experi- 
ence has confirmed this statement, which has of late received 
elucidation from the experiments of M. Brown-Sequard. 
We cannot, therefore, form any diagnosis of the seat of 
disease in respect of the columns of the cord in cases of 
paraplegia from the loss of motility preponderating over the 
loss of sensation, since this happens as a constant pheno- 
menon in all affections which are limited to the cord proper. 
The opinion which I have already expressed about the 
nature of these tumours, in the remarks appended to the 
last case, receives confirmation from the histology of this 
one. It was a vascular tumour, with a nuclear, fibro-nuclear, 
and partly cellular stroma, not invading the tissues around 
it, and not repeated in any other part, and hence probably 
of a simple nature. 

Case 3. — Paraplegia. — Fibro-plastic tumour developed under the arach- 
noid, on the posterior surface of the cord, opposite the seventh and 
eighth dorsal vertebras. (Plate I, fig. 2.) 

William P — , set. 41, admitted under care of Dr. Addison 25th of April, 
1838. A moderately muscular man, of healthy family, and until the com- 
mencement of his present illness his own health has heen remarkably good, 
though his habits have been intemperate. He never remembers to have 
injured his back, but his employment as a blacksmith subjects him to 
laborious, and often violent exertion. He attributes his present state to 



CASES OF PARAPLEGIA. 171 

drinking cold water when heated five years ago, but however this may be, 
about that time he became generally weak, and had cough, attended with 
some expectoration and pain in the left side. His symptoms were not so 
urgent as to induce him to seek medical aid, and after three months' rest he 
returned to his work. This soon brought on pain in the back and left loin, 
with some difficulty in walking. For six months these were his only 
symptoms. He afterwards began to have a feeling of coldness in the legs, 
and occasional loss of sensation. The pain in the lumbar region much 
increased, and prevented his bending the spine in stooping. In June, 1837, 
in addition to an aggravation of all his former symptoms, there was partial 
loss of power in the left leg, the right, however, still preser\ang its integrity 
until the following Christmas, when it also became similarly affected, and 
both were frequently subject to spasmodic jerkings and twitchings. The 
sphincters became weak, and day by day, up to the time of his admission 
into the hospital, he noticed an increase in the paralysis, and of the involun- 
tary contractions of the legs, any attempt at voluntary motion bringing on 
the spasms in an aggravated form. On admission the legs were completely 
paralysed, and also the rectum and bladder, and there was impairment of 
sensation as high as the crista ilii of either side. The loss of sensation was 
less in the left leg than in the right, whei'e, excepting at the posterior part 
of the tibia, it was complete. The least contact of the soles of the feet with 
the floor caused a spasmodic tremulous agitation of the legs, which, even 
when not thus excited, were often thrown about by spontaneous spasms of 
the muscles. Nothing abnormal in the form or direction of the spinal 
column. Eespiration humed. Heart's force augmented. No abnormal 
sounds. Pulse 80. Tenderness on pressure in either hypochondriac region. 
A fortnight after admission pneumonia of both lungs set in, soon followed 
by depression, and he rapidly sank. 

Sectio cadaveris. — A tall, wasted body. The theca vertebralis opposite 
the seventh and eighth dorsal vertebrae distended for rather more than two 
inches, and of a venous colour, from many tortuous vessels distributed 
upon it. When laid open the two arachnoid surfaces were adherent at this 
part, but elsewhere the membranes were healthy. On the posterior surface 
of the cord, and covered by the arachnoid, was a large elongated vascular 
tumour, slightly translucent. This growth had been developed in the pia 
mater. It consisted of a soft yellowish substance, very readily broken up, 
with numerous flattened cellular spaces interspersed through it. The medulla 
beneath was entire, but flattened by compression. The growth had not 
destroyed or invaded the membranous coverings. Under the microscope 
it was seen to consist in some parts, of fine, wavy, fibrous tissue, em- 
bedding elongated nuclei ; in others the nuclei were round or oval, and 
only loosely held together by granular blastema. The right pleura was 
pai-tially coated with a layer of recent fibrin ; there was a similar exudation, 
but to a less extent, on the left pleura. The upper lobe of the left lung was 
solidified, and of a reddish-gi"ey colour from recent pneumonia. On pressure 
the pulmonary tissue gave out a greyish puriform fluid. The lower lobe on 
the same side, and the right lung, more or less extensively throughout, were 
affected with pneumonia in an early stage. Liver large, structure gi-anular 



172 DISEASES OP THE NEEVOUS SYSTEM. 

from commencing cirrhosis. Spleen large. Kidneys large, tissue in- 
jected. 

Remarhs. — The almost complete identity of symptoms in 
this case with those of tlie preceding, though in one the 
tumour was on the posterior, and in the other on the anterior 
part of the cord, may be noticed as bearing upon the remarks 
before made on the functions of the columns. 

The fatal affections of the chest, so common in paraplegia, 
have probably a pathological meaning of much wider extent 
than our pi-esent pathology seems to recognise. I allude to 
the influence of the spinal cord on the pulmonary plexus, 
and to the probable origin of pneumonia from paralysis, or 
a similar state of its centres and intercommunicating cords. 
If not in the present number of the Reports, I hope in a 
future one to illustrate this subject, by cases of pneumonia 
having particular characters and apparently caused by 
disease, as aneurism or tumour, invading the trunks of the 
pneumogastrics and the pulmonary plexus. 



Inflammation of the Spinal Membranes. 

The more rare form of inflammation of the spinal mem- 
branes is where the dura mater is principally affected. This 
may arise from injuries to the column itself, or from cold, 
or phlebitis, or other causes. A remarkable instance is 
recorded by Mr. Simon in the ' Pathological Transactions ' 
for 1855. A girl, aet. 18, had a fall, but soon recovered 
from its effects and walked home, a distance of three or 
four miles. After eleven days pain in the back came on, 
with vague symptoms of pain and tenderness over the body 
not altogether unlike hysteria. The movements of the 
trunk in bed were difficult. This was soon followed by 
numbness and twitching in the extremities, and after a few 
hours by paraplegia, complete in the legs and to a marked 
degree in the aims. The patient died on the fourth' day 
from the beginning of the symptoms. Suppuration had 
taken place outside the dura mater throughout the whole 
length of the spine, and, as in the case below (Case 4), 
there was a burrowing of pus outwards along the course of 



CASES OF PARAPLEGIA. 173 

the nerve-trunks towards the mediastiuum and amoug the 
muscles. The inflammation in this case was limited to the 
outer surface of the dura mater, and appeared to have been 
set up by fracture of the body of the last cervical vertebra 
without displacement. The record of this case is accom- 
panied by a still more remarkable one by Dr. Bristowe, 
where the suppuration was not limited to the outside of the 
theca vertebralis and to the formation of extensive burrow- 
ing abscesses in the course of the nerve-trunks, but the 
cavity of the arachnoid was also full of pus. In this 
instance the history was obscure, and the post-mortem 
examination threw no light upon the excitiug cause. In 
the following case a similar state of things existed, set up, 
as clearly as could be indicated, by exposure to fatigue, wet, 
and cold. This may appear but a vague causation for so 
formidable a malady, but the evidence of other inflammatory 
affections confirms its truth. Almost every day's experience 
affords illustrations of pleurisy and pericarditis referable 
only to such a source, though pathology is at present at 
fault in unveiling the steps which lead to the results. To 
call them " idioj^athic " is to satisfy ourselves with a term 
without meaning, and to call them " rheumatic " is to 
impose upon ourselves the fallacy of the " ignotum 'per 
ignotum." I anticipate that we may hereafter be able to 
trace more of these acute affections to chronic diseases, the 
local influence of which is at present overlooked. Such an 
opinion is confirmed by a survey of already recorded cases. 
For instance, the first case which Abercrombie himself 
gives in illustration of " meningitis of the cord," and which 
he speaks of as " au example of idiopathic acute inflamma- 
tion," was almost certainly set up by phlebitis of the 
cervical veins from chronic disease of the ear. Local 
phlebitis as a source of acute disease has not, except in the 
instances of the liver and brain, received so much attention 
of the profession as its importance deserves. In some cases 
of paraplegia associated with gonorrhoea, lately laid by me 
before the Medical and Chirurgical Society, this was shown 
to be their origin ; phlebitis of the vesical and pelvic veins 
extending to the veins of the spine, and setting up inflam- 
mation of the membranes of the cord. 



174 DISEASES OF THE NERVOUS SYSTEM. 

Case 4. — Paraplegia. — Acute inflammation of the spinal membranes; 
softening of the substance of the cord. 

Charles H — , let. 2^, fair complexion, light hair and eyes ; was quite well 
until Monday, April 21st, 1851. He spent the evening and part of the 
night of that day at Stepney fair, walking about for many hours in the wet 
and cold, and afterwards sleeping in his wet clothes. He affirms he did not 
get drunk nor receive any injury. The following day he was very unwell, 
with pain in the back, extending round the lower ribs, and with aching of 
all the limbs. The third day he was unable to leave his bed from weakness 
of the lower extremities, and numbness extending round the abdomen as 
high as a line an inch above the crista ilii. On the fourth day he began to 
lose power over the bladder, and the urine was afterwards drawn ofB by the 
catheter. He was admitted into the hospital on the ninth day from the 
commencement of his symptoms. There was then complete paralysis both 
of motion and sensation of the lower extremities, with paralysis of the 
sphincter ani and entire loss of power over the bladder. The legs were cool, 
and the skin mottled as from cold. He lay supine, with the legs extended. 
Breathing rather short and interrupted. Pulse 76. Tongue furred, white. 
On the tenth day (May istj, towards evening, the skin became very hot, and 
the pulse rose to 132, Eespiration 30. Abdomen tympanitic. No excito- 
motor movements could be produced in the legs, which lay extended and 
motionless, the muscles flaccid. Eleventh day (May 2nd) : Hands cold. 
Pulse feeble, 132. Tongue dry and brown. Urine drawn off by the 
catheter; acid, sp. gr. 1024. Vomits green bilious fluid. Evacuations 
involuntary. Slight oppression of the brain. Respiration by the superior 
ribs. No abdominal movement. Twelfth day : Insensible. Respiration 
gasping. Pulse very rapid, and scarcely perceptible. Slight convulsive 
movements of the hands. Pupils active. Throughout the progress of the 
case, after admission, no twitchings or spasmodic movements in the legs, 
nor any to be excited by pinching or pricking the skin, nor by the applica- 
tion of heat. Died early on the thirteenth day. 

Post-mortem examination (by Dr. Habershon). — Head not examined. 
On making an incision into the lumbar muscles pus was found upon the 
lamina; of the vertebrte. The spinal canal, external to the membranes, was 
filled with pus from the first dorsal vertebra to the third or fourth lumbar. 
There was a thick uniform coating of pus over the whole of the dura mater, 
but principally on the posterior aspect, except one patch about the first and 
second lumbar vertebrae. In the dorsal region pus surrounded the nerves as 
they left the canal. The dura mater was much thickened, and of a dull 
white colour, except in some parts, which were beautifully injected. At the 
commencement of the cauda equina, and about the lowest portion of the 
cord, there was a layer of pus. The vessels of the cord much distended with 
blood. The cord in the whole of the dorsal and lumbar region exceedingly 
soft, especially at the upper part (as high as the first dorsal), where it was 
almost diffluent. Tiie grey matter was of a deep colour. There was no 
disease of the bones. Slight recent pleurisy on both sides. Pulmonaiy 
tissue healthy, with the exception of slight emphysema. Heart healthy. 



CASES OF PARAPLEGIA. 175 

On eithei' side of the spine, where the anterior branches of the nerves pass 
forward, collections of pus extended along their course for a short distance. 
This was the case with the fifth, sixth, seventh, eighth, ninth, tenth, and 
eleventh dorsal nerves. These abscesses communicated with the pus con- 
tained in the spinal canal. The lumbar nerves were not tlius affected. 
Liver and spleen healthy. Kidneys much congested, and the cellular tissue 
around them cedematous. The small intestines healthy. The mucous mem- 
brane of the whole of the caecum, and five or six inches of the transverse 
colon, affected with acute diphtherite. The solitary glands in the other 
portions swollen. Bladder distended with urine. 

Remarhs. — The extent to which paralysis occurs, in inflam- 
mation of the spinal membranes, may obviously depend not 
only on the amount, and seat, and character of the exudation, 
but also upon the presence or absence of softening or other 
lesion of tlie cord itself. In proportion as the cord is in- 
volved in the inflammatory action will the symptoms usually 
considered characteristic of an affection of the membranes be 
less and less marked, and those of paraplegia predominate. 
It was so in this case. Within thirty-six houi'S from the 
commencement of the disease the patient was unable to 
leave his bed on account of weakness in the legs, and on 
admission there was complete loss of motion and sensation. 
It was also remarkable how entirely the functions of the 
brain were undisturbed throughout, ctmtrastiug, in this par- 
ticular, with a large proportion of the recorded cases of 
acute spinal meningitis. These varieties are explained by 
the conditions which give rise to the disease, the nervous 
temperament of the patient, the degree of attendant para- 
lysis, and the presence of actual disease in the brain itself. 

The collections of pus in the course of the nerves show 
how the inflammatory action may be continued from the dura 
mater along their sheaths. There is a possibility of these 
purulent depots being mistaken for the secondary abscesses 
of phlebitis, from which they are without difiiculty distin- 
guished by their continuity with the exudation upon the theca. 

Case 5. — Arachnitis of the cord folloiving an injury ; paraplegia toivards 
the end of the case. 

For many of the particulars of the following case I am indebted to my 
friend Dr. Wilks. 

Frederick L — , aet. 22, a strong, muscular porter at a railway station, had 



176 DISEASES OF THE NERVOUS SYSTEM. 

his neck and shoulders severely squeezed between the bufEers of two car- 
riages, on the 2oth of September, 1855. He was unable to work for three 
or four weeks, and felt much pain in the right arm, scapular region, and 
down the back, especially between the seventh and tenth dorsal vertebrae. 
The pain was increased by any sudden twist of the body, and extended to the 
abdomen. About a week before he came into the hospital he was again 
obliged to leave his work, on account of tlie severity" of the pain along the 
spine. He was admitted under the care of Dr. Addison, February 6th, 1856. 
There was pain on pressure over the lower dorsal vertebrae, pain in the 
abdomen, and occasional tingling in the hands and feet. The abdomen itself 
was full and hard, with pain on suddenly turning the back, extending from 
the ribs below the umbilicus. Nothing abnormal was discoverable in the 
chest. The pulse was 78. Bowels regular, appetite defective. Tongue 
rather furi-ed in the centre. He was treated by cupping, mercurials, and 
laxatives. On the nth the pain in the back was increased. He had head- 
ache, and his nights were restless and disturbed by dreams. The shooting 
pain in the abdomen continued, and it was noted that the integuments were 
remarkabh- hot and dry. The pulse was 72, with a noticeable sharpness in 
the beat. From this date he became slightly afEected by mercurial action, 
and was apparently improving. He left his bed for several hours in the 
day without inconvenience, still, however, complaining of his former sym- 
ptoms and of pain through the chest. On the 28th he had general febrile 
symptoms, with cough and hurried breathing, and signs of pleurisy at the 
base of the left lung. The abdomen tense; — constipation. Pulse 112. 
Sleep disturbed, by dreams, and by frequent spasmodic twitchings of tlie 
extremities. Complained very much of pain in the lumbar region, on each 
side of the vertebral column, and down the sacnim. Oa the i ith there was 
retention of urine. On the 13th slight delirium, and a marked decline of 
strength. He was scarcely able to move the legs, br.t the sensation on 
pinchmg was acute. He lay supine, sinking to the foot of the bed, his arms 
being too weak to help him to support himself. From this date he became 
rapidly worse, with much cerebral oppression. The urine drawn off daily by 
the catheter was ammoniacal, with large deposit of phosphates. The faeces 
escaped involuntarily. Frequent convulsive twitchings, both of the upper 
and lower extremities. Breathing hurried and laborious. Tongue dry and 
brown. Pulse 108. On the day before his death he lay nearly insensible, 
frequently moaning and sighing. Pulse feeble and iiTegular, 90. Urine, 
drawn off by catheter, copious. Faeces passed involuntarily. He died on 
the 17th, six months from the accident. 

Sectio cadaver-is. — The head was not examined. No injury of the ver- 
tebrae or ribs discovered. Spinal canal and external surface of the dura 
mater healthy. The friends would not permit an examination of the whole 
cord. The part removed corresponded to the lower cervical and eighth upper 
dorsal vertebrae. On opening the dura mater the arachnoid appeared 
remarkably tliickened and Hocculent, from effusion of lymph beneath it. 
The effusion was greatest on the posterior surface of the cord along the 
median line, but at the lower part of the cord it extended round to the 
anterior surface, and upwards for a short distance ; the cord itself was not 



CASES OP PARAPLEGIA. 177 

softened, nor, on repeated microscopical examination of the nervous sub- 
stance at diiferent sections, were any traces of exudation discovered. The 
dura mater had undergone no alteration, except that the inner layer was 
rather opalescent. One or two very small fibroid plates existed on the 
arachnoid. The flocculent effusion covering the cord presented under the 
microscope the usual appearances of inflammatory exudation on serous 
surfaces in the stage of organisation into permanent adhesions. Old adhe- 
sions over the surface of the upper lobes of both lungs. At the lower part 
of the left chest a circumscribed space, containing about a cupful of puralent 
fluid. Pulmonary tissue of both lungs stuffed with softish, yellow, miliary 
tubercles, equally diffused from apex to base. Heart and liver healthy. 
Kidneys large, the cortical portion studded with miliary tubercles. The 
splenic tissue similarly affected. 

Remarks. — This case exhibits the more characteristic 
symptoms of pain attendant on spinal meningitis ; pain in 
the course of the spine radiating through the trunk on any- 
sudden twist, or other movement of the back ; pain, with 
tingling, numbness, and twitchings, in the extremities ; pain 
in the abdomen with hot and dry integuments, and probably, 
if more carefully noted, oscillations of tempei-ature. Oliver 
considered pain having these characters as one of the most 
constant symptoms of spinal meningitis, but, like most sym- 
ptoms, its pi'esence is not invariable. In Case 7 there was 
no pain in the back on movement or percussion, and the 
patient asserted that even a blow of a sledge-hammer on 
the spine would not hurt him, he was so sound there. Yet 
the whole membranes of the cord were thickened and agglu- 
tinated by chronic inflammation. The effusion in this case 
was, as usual, under the close layer of arachnoid, and prin- 
cipally on the posterior surface of the cord, probably from 
gravitation. The character of the tubercular infiltration of 
the pulmonary tissue, and the occurrence of pleurisy with 
suppuration, must, as before noticed, be considered as having 
a probable relation to the state of the cord. 

The following case, though not strictly admissible here, 
since at no stage was there paraplegia, is of great interest 
as an illustration of the apparently slight causes which may 
set up disease about the spine and cord. I am indebted to 
Dr. Wilks for the particulars of the case, and to Mr. Birkett 
for permission to record it. 

12 



178 DISEASES OF THE NERVOUS SYSTEM. 



Case 6. —Suppuration of the spinal membranes and formation of pelvic 
abscess after a blow on the hack with the fist. 

Anthony P — , tet. 15, admitted into Guy's Hospital May istli, 1856, 
under the care of Mr. Birkett. He was employed with his parents in a 
travelling show, and was in good health until three days before admission, 
when, playing with another lad, he received a blow on the back from his 
fist. He thought little of it at the time, but afterwards, the pain becoming 
severe, he applied for admission into the hospital. After the application of 
leeches he was so much relieved that he thought of going out, but the pain 
soon returned more severely, and fever ensued. An abscess formed on the 
right side of the sacrum, which was opened, and continued to discharge, the 
flow of pus being increased by pressure on the abdomen. He continued 
daily to get worse, with much irritative fever, and severe pain in the back. 
During the week preceding his death he was exceedingly restless, and often 
delirious, and complained of pain in all parts of the body, but particularly 
in the exti-emities. His head was generally drawn backwards, as in tetanic 
opisthotonos. On one or two occasions he had loss of power over the bladder 
and rectum, but had no other symptoms of paraplegia, and could move 
freely in bed. He died June 4th, twenty-two days from the receipt of the 
injury. 

Post-mortem examination (by Dr. Wilks). — The external opening at the 
side of the sacrum passed into a very extensive subperitoneal abscess, occu- 
pying the fore-part of the sacrum behind the rectum, and extending over the 
ilia on both sides behind the psoas muscles. The bones were exposed, but 
not diseased. Although the abscess had discharged externally on the 
right side, it was most extensive on the left. It had burrowed up to 
the left side of the last lumbar vertebra, and through the sacro-vertebral 
foramen into the spinal canal. When the theca was opened, it was found to 
contain a quantity of greenish pus, spread over its inner surface, and over 
the cord itself. Tlie dura mater, at the jioint indicated, was softened and 
destroyed, and the Cauda equina was lying bathed in the pus which filled 
the sacral canal. The membranes of the cord were inflamed throughout 
their whole extent, and there was piirulent effusion as high as the dorsal 
region. The dura mater was thickened, its inner surface had lost its smooth- 
ness and transparency, and was of a dull green colour. Pus could be pressed 
out from beneath the visceral arachnoid in considerable quantity. The cord 
itself was firm, and the microscope discovered no morbid condition. On 
opening the cranium, traces of acute arachnitis were found over the whole 
surface of the brain, greenish-coloured lymph being effused into the sub- 
arachnoid tissue, especially at the base. The inner surface of the dura 
mater, around the foramen magnum and on the adjacent part of the occipital 
fossa, was of a greenish colour, from lymph effused upon it. Pleurae healthy. 
Lungs healthy. Bronchial tubes filled with tenacious mucus. Heart normal. 
Lumbar and bronchial glands slightly enlarged, and containing traces of 
tuberculous deposit. Kidneys and liver healthy. No peritonitis nor peri- 
•carditis. 



CASES OF PARAPLEGIA. 179 

Case 7. — Pae-4j>legia. — Chronic inflammation of the spinal membranes; 
oedema and softening of the body of the cord. 

Noah F — , iBt. 46. Admitted into Guy's Hospital, under my care, June 
22nd, 1855. A dancing-master, of rather spare frame and nervoiis tempera- 
ment. His general health has been good. In early life he was addicted to 
venereal excesses, and had gonorrhoea several times. Has taken great 
exercise, and often walked long distances. Can give no account of any 
exciting cause of his present symptoms. Twenty years ago he had gout (?), 
and a return of it ten years ago. After the last attack he became subject to 
headache, dimness of sight, double vision, pinching pains in the neck, and 
numbness about the mouth. He was cupped, leeched, and blistered, without 
benefit, and was then ordered to the sea-side, where he soon recovered. A 
year ago, he noticed he could not give "the step " to his pupils so adroitly 
as he had been accustomed to do, but as he had no other symptom he took 
no notice of this, and continued to follow his profession as usual. Six 
months ago the sphincters became weak, and he began to suffer from obsti- 
nate constipation. His .symptoms became rather suddenly aggravated three 
months ago, when he found, after sitting, he was unable to stand steadily 
for some minutes. He now began to have rheumatic (?) pains in the right 
arm, soreness in the soles of the feet, and numbness in the legs, with 
gradually increasing and permanent weakness in them ; yet he was able, 
until a few days before admission, to hobble about with assistance. The 
symptoms of paraplegia came on with frequent and very troublesome spas- 
modic startings in the legs, and a peculiar sense of deadness round the lower 
ribs. Present condition. — He appears prematurely aged. The cranium is 
well formed. The features very intelligent, but expressive of suffering. 
As he lies in bed he can move the legs feebly, but has no power to stand. 
The sensibility is diminished below the distribution of the seventh dorsal 
nerve, and he has a sense of constriction around the lowest ribs, extending 
to the spine. The inner side of the right arm and foreann feels as if 
" asleep," and the fingers are weak. The excito-motor actions are produced 
by the slightest touch, or by the mere shaking of the bed ; and even when 
quite undisturbed he is greatly troubled by what appear spontaneous startings 
of the legs, but which are really due to the involuntaiy passage of the urine, 
at intervals, through the urethra. The legs are more or less permanently 
flexed. The spine is not in any way distorted. There is no tenderness on 
pressure over the vertebra, nor does the application of a hot sponge give any 
kind of uneasiness. He says his back feels quite sti'ong, and if struck with 
a hammer there, it would not hurt him. There is obstinate constipation, and 
when an evacuation passes he is not aware of it. The urine is acid, and 
without albumen. He has either complete retention, requiring the use of 
the catheter, or continued dribbling. Pulse 92, feeble. Tongue moist, 
coated with whitish fur. Frequent profuse sweats. Emaciation. A few 
days after admission the urine became ammoniacal, and dribbled away con- 
tinually, producing excoriation of the scrotum and a bedsore over the left 
trochanter. The rigidity and flexion of the legs increased, and rest was 
prevented by the continual spasms of the lower extremities, which were .so 



180 DISEASES OF THE NERVOUS SYSTEM. 

violent on one occasion as to jerk him off the bed on to the floor. On the 
1 6th of July he was attacked with sickness and hiccough, and became alto- 
gether so much worse that his friends removed him home. He was visited 
at intervals until his death, October 2ist, 1855. During the three months 
from his leaving the hospital he gradually emaciated. The legs became 
permanently drawn up, the heels to the nates and the knees to the abdomen, 
the muscles flaccid and wasted. Any attempt to move them gave him great 
pain. The urine constantly dribbled away. The large intestines were 
emptied by enemata. Bedsores formed over the trochanters and sacrum, 
exposing the bones to a great extent. The feet became cedematous, and a 
large slough formed on the heel from pressure. The tongue became dry, the 
mouth aphthous. He had frequent vomiting. His intellect remained quite 
clear, and his mind tranquil, to the end. Though sensation was diminished 
in the lower extremities, he retained the power of telling which toe of 
either foot was touched. The slightest touch of the feet or succussion of 
the bed set the whole of the muscles of the lower extremities into increased 
contraction, and gave him great suffering. It was easy to see how an 
advance of disease into the cord would have greatly mitigated his miserable 
symptoms. 

The cord only was examined post mortem. I was assisted by my friend 
Dr. Habershon. 

The bony canal was healthy, except a very slight prominence of the inter- 
vertebral substance at the lower part of the dorsal region, which, though 
unimpoi-tant in this case, was worthy of note in reference to some cases of 
paraplegia recorded by Mr. Key. The whole of the spinal membranes, from 
the lower part of the cervical region, throughout the dorsal, and to a less 
degree in the lumbar region, were much thickened, and adherent together. 
The posterior layer of the dura mater in the upper part of the dorsal region, 
was indurated by bony plates between its laminae. These, examined micro- 
scopically, presented the characteristic osseous lacunae and canaliculi, but 
differing from the normal bone of the skeleton in the larger and more 
variable size of the lacunse, and the less numerous and delicate channellings 
of the canaliculi. Dr. Wilks, who, as well as myself, examined them, 
noticed that the lacunae had a disposition to arrange themselves in concentric 
rings, being formed into parcels or systems by fibrous columns running 
between them. The ai-achnoid was quite opaque and very thick. The pia 
mater also was much thickened. The body of the cord throughout the whole 
of the dorsal region was wasted and soft. The surface of the columns under 
the pia mater wa.s translucent from granular exudation. Among the 
nervous tubules there was abundant granular exudation and granule cells. 
The continuity of the columns was nowhere interrupted. The lesions were 
due to chronic inflammation of the dura mater and more recent subacute 
inflammation of the other membranes, extending to the body of the cord. 
The bony plates of the dura mater were seated in the substance of the 
thickened membrane itself, and probably arose from the degeneration of new 
fibrous tissue. There were none of the opaque pearly plates so common on 
the arachnoid of the spine. This membrane was very thick, and its sui-faces 
agglutinated by firm but recent adhesions. 



CASES OF PARAPLEGIA. 181 

Remarks. — The absence of pain and tenderness in the 
course of the spine was remarkable in a case where the 
membranes were so extensively affected ; neither was there 
the exalted sensibility which Olivier regarded as pathogno- 
monic of affections of the spinal membranes. The sym- 
ptoms throughout corresponded, in a great degree, with 
those observed in cases of tumours producing pressure on 
the cord, with the important exception of there being no 
local pain in any part of the back. There was rather numb- 
ness than exalted sensibility, and yet withal, great pain 
towards the end of the case, when the paralysed extremities 
were moved. Cruveilhier has di'awn attention to this sym- 
ptom of paraplegia from spinal meningitis. His conclusion, 
though scarcely confirmed by this case, may, perhaps, be 
noticed here. He states that, " in paraplegia from spinal 
meningitis, there is — ist. Paralysis of the cutaneous nerves, 
gradually and successively invading the lower extremities, 
the trunk, and the upper extremities ; at first limited to a 
portion of a limb, afterwards affecting the whole, and thence 
extending to another. 2nd. Muscular paralysis in the first 
period, from pain ; and muscular paralysis with anfesthesia 
in the second period. The muscles are painful on pressure, 
in voluntary or involuntary contraction, or when moved me- 
chanically. In the first period there is voluntary power to 
move the muscles, if an effort be made to overcome the pain ; 
but after a short time the pain increases so that the will is 
powerless over the muscle. The tenderness of the limbs is 
not due to exaltation of the cutaneous sensibility, as the 
skin is insensible, but to a painful state of the muscles them- 
selves.'^ 

The painful state of the muscles here described did not 
exist in this case, nor did the pain on moving the rigid and 
paralysed extremities appear to arise from the muscles, but 
from the state of the joints, or the parts about them, due to 
long- continued immobility. Though a degree of ana)sthesia 
occurred in the advanced stage of the case, the symptoms 
were not, as Cruveilhier states, ushered in by an affection of 
the nerves of sensation, but, on the contrary, of the nerves 
of motion ; and though it is obvious there may be cases 
where, from the inflammation affecting the posterior roots of 



182 DISEASES OF THE NERVOUS SYSTEM. 

the nerves as tlaey arise from the cord, alteration of cutaneous 
sensibilit}^ may be an early symptom, yet we can scarcely 
understand how it should have any such necessary law of 
gradual and successive invasion as that here laid down, 
since it is obvious this must depend upon the locality and 
character of the effusion, and will vary with the case. 

The apparently centric spasms which affected the para- 
lysed extremities, and occasioned this patient so much dis- 
tress, were really excito-motor , and due to the dribbling of a 
few drops of urine, at short intervals, along the urethra. 

As to the causes which gave rise to this extensive chronic 
inflammation of the membranes, I learned, after the patient's 
death, that he had on one occasion a very severe fall upon the 
back, and after that, his symptoms gradually came on. He 
himself attributed his paralysis to the fatigue of his occupa- 
tion. 

Beginning with languor and partial loss of motion, with 
the entire absence of local symptoms in the spine, in a man 
having the occupation of a dancing-master, and who had 
exhausted his system in many ways, his symptoms were not 
unlikely to be attributed to mere debility, and to be met by 
tonics and stimulants, instead of being combated by such 
means as arrest inflammation. Taken at the onset, there is 
reason to believe much benefit would have followed a 
judicious and rigid treatment. 

Case 8. — Paraplegic weakness of the upper and lower extremities ; wasting 
of the muscles ; mental confusion and delirium ; increased sensibility 
of the ivhole surface. 

Mrs. — , fet. 37, married ; mother of four children. Previous to her 
present illness her health was impaired by an attack of cholera, and chronic 
diarrhoea, and probably also by habits of intemperance. About the end of 
March, 1850, she began to complain of pain in the back, wandering pains 
about the body, and of weakness and pain in the knees and ankles, supposed 
to arise from rheumatism. In a short time she was unable to walk, and the 
upper extremities became generally weak. The hands dropped, and hung 
flaccid and loose from the wrists. The muscles of the upper and lower 
extremities wasted, but especially of the parts most removed from the 
centres, as those of tlie thumb, the interossei of the fingers, and the muscles 
of the foot and calf. As the paralytic symptoms came on there was a 
general change in the mind. Slie became cunning, more fond of drink, and 
inconsistent and trifling in her manner, and at times delirious. When 



CASES OF PARAPLEGIA. 18S 

admitted into the hospital, June 5th, 1850, there was tremor and great 
mental confusion, but she retained so much consciousness as to be able to 
tell the number of fingers held up, and to put out the tongue when bidden, 
though she did it but imperfectly. On the 30th she lay supine, sinking to 
the foot of the bed. Pulse 120. Respiration 36. Skin hot. Tongue dry 
and brown. Muttering delirium. Sufficient consciousness to partially protrude 
the tongue when told to do so. Both hands dropped, and useless, yet she 
has power to move the arms. The legs are extended ; she is unable to flex 
them, though she can slightly move the toes, and make the muscles of the 
legs contract to some extent by an effort of the will. Sensation not impaired. 
Complains bitterly when the legs are moved, and there is general increased 
susceptibility to pain over the whole surface. Speech and deglutition 
imperfect. Urine and fseces passed involuntarily. No deafness. Pupils 
rather large, but contract freely on the stimulus of light. Prom the above 
date the breathing became gradually more and more embarrassed, from the 
imperfect power to raise the lower ribs and to use the diaphragm. The 
respiration was entirely superior-thoracic, the abdomen falling in at each 
inspiration. There were slight twitchings of the hands, but the legs lay 
extended and motionless, nor could any excito-motor movement be produced 
by irritating the soles of the feet. She died from asphyxia, July 5tli, 1850. 
Sectio cadaveris. — The spinal cord was examined first. On laying open 
the theca the cerebro-spinal fluid appeared to be much increased in quantity, 
though still limpid. The membranes presented no obviously abnormal 
appearance. At the origin of the third, fourth, and fifth cervical nerves, the 
cord seemed, as the finger was lightly passed over it, rather softened, but a 
careful microscopical examination of several sections gave no evidence of 
any structural lesion. The grey matter was pale. Except increase of the 
subarachnoid fiuid, and paleness of the grey substance of the convolutions, 
the brain was healthy. No increase of fluid in the ventricles. The phrenic 
nerve and the nerves of the brachial plexus on both sides were examined, 
and found healthy in their general and microscopic structure. The wasted 
muscles were pale and flaccid, but preserved their normal microscopic 
appearance. The parietes of the body, notwithstanding the great muscular 
atrophy, were covered with fat to the thickness of nearly an inch ; the 
mesentery and omentum, and also the heart, loaded with fat. The right 
lung adherent to the parietes by old cellular adhesions, and by a deposit in 
these, of hard, fibrous, scirrhoid masses. The pleura pulmonalis, on the left 
side, was studded with numerous small tubercles, and partially adherent by 
tough false membranes. The cervical glands were affected by a deposit 
similar to that on the pleura. Liver large and pale from fatty degeneration. 
Kidneys healthy. 

Remarhs. — The origin of this case seems to have been a 
cachexia from previous disease and intemperance^ leading to 
chronic cerebro-spinal meningitis and dropsy of the mem- 
branes, with atrophy of the cord and brain. The clinical 
history and post-mortem appearances indicate a relation to 



184 DISEASES OF THE NERVOUS SYSTEM. 

general paralysis of the insane, with this, amongst other 
points of difference, that the spinal centres were more 
affected than in that disease. The extreme wasting of the 
muscles of the forearms and hands, and of the legs and 
feet, whilst the paralysis was still incomplete, led to a sus- 
picion of primary degeneration, either of the muscular fibre 
or of the nerve-trunks, but this was not confirmed by micro- 
scopical examination. 

Increased membranous effusion, probably producing pres- 
sure, defective nutrition, slight softening, and paleness of 
the grey matter, were the only anatomical lesions to which 
the paralysis was attributable, and to what extent the 
centres of the cord had lost their functions may be inferred, 
not so much from the loss of voluntary power, as from the 
great muscular atrophy, the total extinction of the excito- 
motor actions, and death from paralysis of the chest. 

As an illustration of paraplegic affections, the case belongs 
to the class which has been termed "encephalic,^' or 
" cerebro-spiual," as distinguished from the cases which 
have a peripheral, or a strictly spinal origin. It includes a 
large number of cases of paraplegia which come on after or 
about the middle period of life, where at first the loss of 
power is not so obvious as the want of management of the 
muscles ; the memory becomes defective, the temper irri- 
table ; the pupils inactive, and often contracted. 



Case 9. — Paraplegic rigidity of the muscles of the upper and lower 
extremities froon limited arachnitis of the cervical portion of the cord, 
the affection of the upper extremities preceding that of the lower for 
some months. 

Mrs. L — , set. 33, motlier of one child, now fourteen years old. General 
health very good. Catamenia regular, up to the present time. Six months 
ago, having felt generally weak for a short time previous, and after a day's 
washing, went to bed as well as usual, but on waking the following 
morning her joints were painful but not swollen, and she was unable to 
move her arms. Under treatment by cupping and blisters between the 
shouldere she recovered in a fortnight, and returned to her ordinary duties, 
having no uncomfortable symptoms but pain in the left shoulder. After 
another foi-tnight the muscles of the arm again became rigid, the affection 
beginning in the shoulders and extending down the arms, so that at last she 
was totally unable to move them. For four months after this the legs were 



CASES OF PARAPLEGIA. 185 

but little affected, and she could walk until within five weeks of her admis- 
sion, the arms, however, remaining quite useless from the rigidity of the 
muscles. On admission, under the care of Dr. Addison, February, 1854, her 
symptoms were as follows : — She is quite unable to move either the arms or 
legs, except to a trifling degree, the left foot. The muscles of expression, of 
speech, and of deglutition, are unaffected. Slight anaesthesia, yet she com- 
plains of very severe pains in the knees and arms. The muscles are well 
nourished and very rigid. On making efforts to pass the evacuations or 
urine, the whole trunk and extremities become extended and more rigid. 
No pain in the spine at present, but formerly she had much in the neck and 
about the back of the head. Power over the bladder diminished, but the 
urine can be voided at will with some effort. Bowels constipated. Respira- 
tory movements thoracic, heaving, and compact, not uniformly undulating. 
She complains much of a sense of suffocative constriction about the throat, 
and in speaking has no breath ; nor can she cough, sneeze, or blow the nose. 
Speech unaffected. No affection of the nerves above the second cervical. 
General nutrition very good. Aspect healthy. Pulse 96. Respiration 16. 
Arms extended and rigid. The pain complained of in the joints depends 
upon the position of the limbs and the tension of the muscles, and is directly 
relieved, for a time, by changing their position. She has fits of shivering, 
which she calls hysterical ; these are accompanied by increased dyspnoea. 
Frequent sudden spasmodic extension of legs and arms. No discoverable 
lesion in the bones or ligaments of the cervical portion of the spine. The 
pain complained of at tlie back of the head and neck, at the beginning of her 
illness, has not returned since the cupping. March 19th. — No change in the 
symptoms. The left pupil is smaller than the right, and the vision of the 
left eye is imperfect, and has been so for ten months. She again complains 
of an aching pain in both sides of the neck, near the occiput. Pulse 120. 
Respiration heaving and thoracic. The excited condition of the pulse is 
constant, and she is subject to frequent palpitation. April ist. — General 
health remains good. Limbs rigid, especially tlie arms. She can sit upright 
in bed, firmly and without support, when placed in that position. The 
movements of the head on the atlas, and of the atlas on the axis, are free. 
Power over the sphincters diminished, but not lost. Pulse 90. Respiration 
18. 13th. — Retention of urine. May 14th. — During the last few days she 
has had a severe pain in the head, so severe, she says, as almost to deprive 
her of reason. She complains bitterly of it. The sense of strangulation is 
very urgent. Pulse 48. Respiration 14. No delirium nor incoherence. 
Pupils both act on the stimulus of light ; the right, as noted before, is the 
largest. Yesterday she was bled from the arm, without relief. On the 
15th she was delirious, and died on the morning of the i6th. 

Sectio caclaveris. — Subcutaneous tissue veiy fat. Voluntary muscles 
generally pale but healthy, except some of the fibres of the soleus, which had 
degenerated. Slight subarachnoid effusion on the surface of the brain. 
Moderate quantity of clear fluid in the lateral ventricles. Cerebrum, cere- 
bellum, pons Varolii, and central parts healthy. Floor of the fourth 
ventricle rather opaque, the membrane closing it thickened and bulged 
from the accumulation of fluid in the ventricles. The membranes 



186 DISEASES OF THE NERVOUS SYSTEM. 

o£ the cord thickened and completely adherent together about the origin 
of the third cervical nerves. Above this the adhesion extended so as 
to implicate the origins of the second and first cervical, and on the right 
side also some of the lower fibres of the origin of the pneumogastric and 
lingual. The root of this latter nerve on the right side was embedded in a 
mass of opaque inflammatory exudation, and a similar mass intervened 
between the membranes anteriorly. The roots of the whole of the cervical 
nerves and of the spinal accessory were matted together by old thickening 
of the dura mater and arachnoid. The cavity of the arachnoid was oblite- 
rated anteriorly throughout the whole of the cervical region, and posteriorly 
also to a somewhat less extent. The cervical enlargement and the superior 
part of the dorsal portion of the cord to which the membranes were adherent 
was softened, and contained numerous granule cells. The whole of the local 
changes appeared to have resulted from inflammation. The yellow mass 
about the root of the lingual nerve consisted of dead exudation, and con- 
tained the debris of inflammatory corpuscles. The other smaller mass 
intervening between the membranes consisted in parts of cells and nuclei, 
and in part of fibre cells, and in one portion was organising into distinct 
areolar tissue. The bones and ligaments were healthy. Lungs and heart 
healthy, except slight and old adhesions about the centre of the left lung, 
and a white patch on the surface of the right ventricle. The liver contained 
an excess of fat. Kidneys congested. 

RemarJiS. — There are few points in paraplegia which 
present more difficulty than the determination at the bed- 
side of the causes which have given rise to the disease. In 
a large pi'oportion of cases some event, which, from an 
accident of time only, has associated itself with the accession 
of the more marked symptoms, is the prominent one in the 
mind of the patient. It was so in this case ; no account 
could be given of a reliable cause of the inflammation, 
though from the anatomical conditions of the membranes 
post mortem it may be inferred that some local injury set 
it up. It is worthy of note that cupping and blistering at 
once removed the acute symptoms of the first attack, and it 
is probable that due care would have obviated further con- 
sequences. The case was characterised by rigidity and 
extension ; the muscles continued to be well nourished. 
The principal pain complained of by the patient was from 
the pressure of the extremities upon each other, from the 
tension of the muscles, which was for the time relieved by 
changing their position. The upper part of the cord was 
clearly indicated as the seat of the disease by the pain in 
the neck and the sense of constriction around the throat, as 



CASES OF PARAPLEGIA. 187 

well as by the paralysis of the wall of the chest, the patient 
being unable to cough or sneeze. As frequently happens 
where the upper segments of the cord are affected, the arms 
were paralysed for some time before the legs. The irregu- 
larity of the pupils is probably referable to implication of 
the roots of the upper cervical nerves in the inflammatory 
thickening. Such a symptom is of interest in diagnosis, 
and one often misinterpreted as due to cerebral disorder 
when its source, as proved by modern physiology, may be 
entirely spinal. The acute affection of the membranes of the 
surface and of the ventricles of the brain which ended the 
case is worthy of note, as associated with the lesion of the 
membranes of the cord. It was also remarkable how 
suddenly, with the supervention of the cerebral symptoms, 
the pulse, previously ranging from go to 120, fell to 48. 

Case 10. — Paraplegia coming on siiddenlij after fatigue and exposiire to 
cold, and unattended by any derangement of the general health; 
softening of the cord in the dorsal region. 

John H — , set. 20, a healthy, florid young man of the middle stature, 
occupied as a brickmaker. On the iSth of July, 1855, he walked twenty- 
eight miles to look for work, and slept in a brick-field. The next day he 
walked thirty-two miles. The day was close and wet, and he allowed his 
wet clothes to dry on him, without feeling any immediate inconvenience. 
The following morning (July 20th) he was quite well, and went out to see a 
cricket match. He had no stiffness in the limbs nor pain in the back. He 
took his dinner as usual, about midday, and in the afternoon, whilst 
sauntering in his garden, his legs suddenly gave way under him, and he fell 
down. He was, however, able to get up again without assistance, and to 
return into the house. About two hours afterwards he walked upstairs to his 
bed, feeling, as he says, all the time, " pins and needles " from the thighs to 
the feet. Retention of urine came on at this time, and the bowels were quite 
inactive. About a fortnight before his attack he had some slight warning, 
in not being able on one occasion to pass his water for twelve hours, but 
from that time until the sudden accession of his symptoms in the afternoon 
of the 20th he had no further inconvenience of any kind. About seven 
months since he had a chancre, but no secondary symptoms. Never had 
stricture. On admission, under the care of the surgeon (July 26th), there 
was complete paraplegia. Involuntary twitchings and spasms of the legs 
towards night. Slight excito-motor movements on touching the soles, but 
not on irritating the skin of other parts of the feet or legs. Gradually 
increasing anaesthesia below the umbilicus, but nowhere complete. Bladder 
much distended, with slight dribbling of urine. No priapism at the onset 
of the symptoms. He lies on his back, with his legs extended and the hands 



188 DISEASES OF THE NEEVOUS SYSTEM. 

under the head, with an air of entire indifference as if nothing ailed him, and 
says he does not feel in any way ill. Tongue clean and moist. Appetite 
good. No headache. Pulse 90, heat sharp. Respirations 21. Motions of 
lower ribs imperfect. For the last two days he has had some pain in the 
loins, bvit none previously. The spine is normal. Slight tenderness about 
the third and fourth lumbar vertebrae. A large bulla on the sole of the left 
foot from hot applications. Empl. Lyttae lumbis ; Jul. Hyd. Bichl. 5j) ex 
Dec. SarzjB, ter in die. July 28th. — Complains of a sense of burning in both 
legs below the knees. Excito-motor action well marked in left leg, much 
less in right. By straining his abdominal muscles he can force a little urine 
out of the distended bladder. Ui'ine contains mucus, and is alkaline from 
ammonia. Pulse 100. Respiration 28. Skin cool. He says he should be 
well if only he could move his legs. Vespere. — Had a slight rigor about 
midday. Skin hot. This rigor was probably due to a false passage made 
yesterday by the catheter. 29th. — Return of rigors. Legs extended and 
entirely paralysed, with now and then a slight involuntary jerk. The 
electro-contractility, even with weak currents, well marked, the electro- 
sensibility reduced to a perception of a faint tingling, even when the inter- 
rupted current is powerful. August 7th. — Sensation of -the legs slightly 
returning ; this is most marked in the right leg. He has no sense of tight- 
ness round the waist. Excito-motor movements are now more readily pro- 
duced, and follow not only when the soles of the feet, hut even when the 
skin of the insteps and over the legs is nipped sharply. Tongue clean. 
Appetite good. Skin cool. Pulse 80. Urine pale, contains mucus, and is 
alkaline from ammonia. loth. — Rigors, sickness, hectic. Urine highly 
ammoniacal. Sloughs forming over sacrum. Rapid emaciation. i8th. — 
Rapid failure of strength. Frequent vomiting. Pulse 120. Skin clammy. 
Died exhausted, without delirium, Augi;st 20th, 1855. 

Sectio cadaveris. — Body greatly emaciated. Several small superficial 
sloughs over the sacrum. On opening the spinal canal the sheath of the 
cord appeared to be more distended than usual ; the inner surface of the 
dura mater rather opalescent. There was no abnormal adhesion nor any 
effusion of lymph upon the membi'anes ; they had generally an anaemic 
appearance. At the middle of the dorsal region there was marked softening 
of the cord, with slight enlargement. The softening was most marked for 
the extent of half an inch about the origin of the eighth dorsal nerve, but in 
a less degree for an inch above and below this point. There was no apparent 
vascularity about the part. On a transverse section the posterior columns 
were quite diffluent, the anterior softened but retaining their form. The 
gi'ey matter was mottled by injection of its vessels. The columns were 
opaque white. As a general examination of the body was not permitted, the 
kidneys and urinary organs were removed from behind. The kidneys were 
large ; weight 17 ounces ; the texture soft, and mottled by purulent infiltra- 
tion into and amongst the tubules. Mucous membrane of the pelvis con- 
gested and ecchymosed. Bladder full of purulent and ammoniacal urine. 
Its lining membrane inflamed and sloughing. There were three false 
passages from the urethra into the bladder. One of these communicated 
with an extensive abscess behind the bladder, and another with a smaller 



CASES OP PARAPLEGIA. 189 

abscess situate to the right side of the membranous portion. On a micro- 
scopical examination of the cord the posterior columns were found to be the 
seat of exudation in the form of irregular masses of granules, either free or 
collected around softened and broken-up nerve-tubules, and of granule-cells 
scattered throughout the dorsal and the lower part of the cervical region. 
The extent of this change was much greater than was indicated by the 
softening -visible to the naked eye. The surface of the columns contained 
more exudation than the more central parts, and the white substance more 
than the grey. The slight mottling of the grey matter was due to injection 
of loops of capillary veins. 

Eemarhs. — The striking feature in this case was the sudden 
occurrence of the paralysis without any local symptoms of 
pain or uneasiness about the spine, neither was there at any 
time that sensation of a band-like constriction round the 
abdomen which is often characteristic of disease in the dorsal 
portion of the cord. From this and other causes, it seems 
probable that this symptom is more marked when the mem- 
branes and parts about the cord are affected, than when the 
lesion is limited to the nervous tissue only. It may have, 
probably, three different sources : it may arise from a sub- 
jective state of the spinal centres at the seat of disease, 
referred by the patient to the course of the nerves arising 
there ; or from distension of the abdominal viscera as a 
result of the paralysis ; or from disturbance of the muscular 
action of the diaphragm, and paralysis of the lower inter- 
costals. 

The absence of all constitutional symptoms during the 
early part of the case was remarkable. The patient had an 
air of entire indifference, and insisted that he felt well but 
for the paralysis of the legs. If the law proposed by 
Duchenne had been relied on, it would have led to a grave 
error in diagnosis ; this author having given it as a test of 
hysterical paralysis, that electro-contractility is unimpaired, 
whilst electro- sensibility is lost, yet this was the case here, 
on the ninth day of the symptoms, with acute softening of 
the cord. 

If we may conclude from the presence of granular matter 
and " granule-cells " that the softening was the result of an 
inflammatory process, the amount of solid exudation is still 
remarkable. It seems probable that there is some prior dis- 
turbance of nutrition of the nervous tissue, of which the 



190 DISEASES OF THE NERVOUS SYSTEM. 

traces of inflammatory action are but an after result. The 
pathological conceptions we may form on this point are not 
unimportant, for at present the theory of inflammation which 
obtrudes itself where acute lesions of structure occur, sug- 
gests such means of treatment as not only clinical expe- 
rience but the anatomical conditions themselves show to be 
very doubtful. Looking at the anaemia of the membranes, 
the oedema and softening of the columns, the small 
amount of exudation, without any traces of plasticity, it 
seems probable that a supporting rather than a depletory 
system of treatment is most likely to favour repair ; certainly 
the indications, both clincal and pathological, are opposed 
to the old empiricism, with its cupping, and blistering, and 
calomel. 

Why the dorsal segments of the cord should be so fre- 
quently the seat of this form of softening is worth inquiry. 
It is a part where injuries are most felt, and probably the 
reparative power is less than in the lumbar or cervical 
regions, where the segments are more highly organised. 
Death resulted in this case from pelvic imflammation and 
abscess, probably not altogether independent of false pas- 
sages made by the catheter. 

Case ii. — Paraplegia. — Subacute softening of the cord in the cervical 
region; large osseous and fibroid plates on the visceral arachnoid. 

Bridget C — , set. 30. Wife of a labourer ; mother of four children ; no 
miscarriages. Always had good health until six months ago (the fifth 
month o£ her last pregnancy), when she began to have pains in her knees 
and feebleness o£ gait. With these symptoms there was also some pain in 
the neck, between the shoulders, and down the back. The hands became 
slightly numb, their grasp feeble, and the muscles rapidly wasted. The legs 
were ocdematous, and it was with great difficulty she continued to walk 
about until her confinement. Her labour was tedious, but accomplished 
naturally. The child was stillborn. Since her confinement, now five weeks 
ago, she has not left her bed. She has but slight power over the movements 
of the legs. The urine has continually dribbled from her, and there has 
been but imperfect control over the rectum. When admitted she was sup- 
posed to be labouring under paralysis of the bladder, from the effects of her 
recent labour. Two pints of highly ammoniacal urine were drawn off by the 
catheter. The respiration was said to be natural. Pulse 100. She was in 
a very helpless state from the paralytic weakness of the legs and arms. The 
dyspnoea and thoracic oppression were painfully urgent ; she said she felt as 
if she wanted the space of the whole room to breathe in. She lay supine, 



CASES OF PARAPLEGIA. 191 

and preferred the liorizontal position, objecting, so far as she conld spare 
breath to do so, against being placed in a more upright position. Pulse 120. 
Respiration 30, with noisy bronchial wheezing. Muco-purulent secretion 
from the conjunctiva partially gluing the lids together. Cough feeble and 
ineffectual. Expectoration very difficult, muco-purulent, frothy, and viscid. 
Urine drawn off by the catheter, high-coloured and alkaline, with mucus and 
phosphates. Bedsore forming over sacrum. Intellect clear. Face livid. 
Feet warm. No anaesthesia either in extremities or trunk. Sense of weight 
and constriction over chest. December 6th. — Symptoms of bronchitis set in 
this morning, with great oppression of the breathing. No expectoration. 
7th. — Expectoration viscid and muco-purulent. Tongue furred. Pulse 100, 
very feeble. 8th. — At this date the patient was placed under my care. It 
was now obvious from her respiration that all the intercostals were paralysed. 
Instead of the chest expanding in her efforts to inspire, the walls of the 
thoi'ax fell in to a marked extent with each descent of the diaphragm. 
12th. — Horizontal and supine position the same. No power to move in bed. 
Great dyspnoea. Respiration 44, entirely diaphragmatic. Expectoration 
very difficult, muco-purulent. Pulse 150. Skin hot and perspiring. 
Muscles of upper extremities much wasted, but she can lift the arms over 
the head. Slight anajsthesia of the fingers of both hands. No involuntaiy 
movements of the legs. Muscles flaccid. Abdomen distended. 14th. — 
Somewhat relieved of the dyspnoea by the use of sulphuric ether and brandy 
mixture. The expectaration lost for a few hours its puriform character and 
became serous. She died on the 18th, from gradual obstruction to the 
respiratory movements and accumulation in the bronchial tubes. 

Sectio caclaveris. — Body moderately well nourished. Commencing bed- 
sore over sacrum. Head not examined. Spinal canal free from disease. No 
inflammatory products nor abnormal adhesions of the spinal membranes. 
Numerous fibroid and osseous plates, some unusually large (six lines in 
length by four broad), on the visceral arachnoid, mostly on that of the pos- 
terior surface of the cord, and almost limited to the dorsal and lumbar 
regions. Many of these contained the lacunae and canaliculi characteristic 
of true osseous structure. Others had partly a fibroid and partly a hyaline 
basis, with nuclei and lacunas in it. The substance of the cord at the origin 
of the fifth and sixth cervical nerves was much softened. The softening 
principally affected the posterior columns and the posterior half of the left 
lateral column. The tissue was flocculent, and filled with granular matter 
and granule-cells. The disoi'ganisation had most advanced at the surface of 
the cord, which was of a faint ochrey tint. Tlie vessels of the pia mater at 
this part were full of blood. The principal softening was very much limited 
to the point indicated, but for three or four inches higher up granule-cells 
were found scattered amongst the fibres of the posterior columns. Lungs 
healthy. Bronchi full of muco-purulent secretion. Heart and pericardium 
healthy. Kidneys healthy, 9I ounces avoirdupois. Spleen 4 ounces. Pelvic 
organs healthy. Lining of bladder apparently healthy. 

Remarks. — The cause of the softening" is in this case, as it 
is in most others, obscure. Contrary to the statement of 



192 DISEASES OP THE NEEVOUS SYSTEM. 

those pathologists who have asserted that in acute softening of 
the cord the grey matter is most affected^ the disorganisation 
had in this case advanced most at the surface ; and although 
the disease was limited to the posterior columns, yet motion 
was principally affected. One of the chief points of clinical 
interest in the case was the error in diagnosis at the early 
part of it, when the paralytic symptoms were attributed to 
injury of the pelvic nerves, and the dyspnoea and bronchitis 
not recognised as the effects of paralysis of the chest. 

Case 12. — Paeaplegia. — Softening of the cord, 'jprincijpally at the Imnbar 
termination, but extending upwards throughout the whole length of 
the posterior columns ; great congestion of the cauda equina ; para- 
lysis of right third nerve from disorganisation of the ti-unJc near its 
origin. 

October 29th, 1855. — William L — , set. 52. A tall man, with broad, well- 
developed frame, twice married, and the father of a large family. Had 
syphilis several years ago. At the commencement of his present symptoms 
liad enlarged testes, for which he was treated with iodide of potassium. He 
dates his illness from four years ago, on getting wet and fatigued and 
allowing his wet clothes to remain on him, subsequently travelling to 
Exeter, and probably sleeping in a damp bed. Seven weeks afterwards he 
began to ha^e pain in the loins and difficulty in passing his urine, which was 
high-coloured and ammoniacal. It was not until two months later that the 
first distinct symptoms of paraplegia showed themselves by weakness in the 
knees, and a sense of weariness in walking, which often obliged him to rest. 
He, however, continued to transact his business as a dye-wood cutter during 
the years 1852-3, and part of 1854, until at length he applied as an out- 
patient at the London Hospital. His paralytic symptoms were at this time 
attended with severe pain running down the right leg, supposed to be 
sciatica. At first he was able to walk from his house in Limehouse to the 
hospital, but soon the legs became too weak for this, and he was much 
troubled, especially at night, with spasmodic retraction of them to the 
abdomen. The paralysis now became complete in the right leg, and he con- 
tinued to suffer from the severe neuralgic pain, commencing about the last 
dorsal vertebra and shooting down the leg to the sole of the foot. The left 
leg was occasionally the seat of the same kind of pain. Six months after 
becoming an out-patient of the hospital the sphincters failed him, and large 
bullai formed on the soles of the feet. He now became an indoor patient 
for four months, without any obvious change in his symptoms, until about a 
week before his admission into Guy's, when one morning on waking he found 
himself unable to raise the right eyelid. October 29th, 1855, he was in the 
following condition : — Complete paralysis of the right leg. Can flex the left 
thigh to a slight extent. QDdema of both feet. Slight electro-contractility 
of the muscles of the left leg. Electro-sensibility above the knee on this 



CASES OF PARAPLEGIA. 193 

side in excess. Neither electro-contractility nor sensibility in right leg. No 
excito-motor action in right leg, slight twitches of left. Pain at the last 
dorsal vertebra, extending down the legs to the soles of both feet. When 
the feet are roughly touched or pinched, the sensation is painful and 
burning. Ptosis of the right eye ; paralysis also of the superior, inferior, 
and internal recti, with dilated pupil. Diplopia of objects to the left. 
Transient numbness in both hands, with slight permanent diminution o£ 
sensation in the right ; no want of power in either. Tongue protruded 
straight. Deglutition good. He retains some power to empty the bladder ; 
urine not albuminous, acid. Bowels inactive. No sloughs on back. No 
sense of constriction round the trunk. November 14th. — Paralytic sym- 
ptoms unchanged. During the last four days he has complained much of 
headache over the forehead and vertex, and the pain down the back is more 
intense. To-day his manner is quick and talkative, with slight delirium. 
Tlie urine dribbles into the bed. Bladder distended. He complains of 
chilliness, and yesterday there was a perceptible coldness of the left arm and 
hand. Eespiration normal. Pulse 84. Diarrhoea. November 24th. — Has 
taken no food to-day. Lies in a dull and listless state, from which he can 
be only partially roused. Speech indistinct. Both pupils largely dilated, 
right inactive, left contracts on the stimulus of light. Urine drawn off by 
catheter, abundant, light amber colour, rather turbid from mucus, faintly 
alkaline. Pulse slow and labouring. Bowels inactive. November 28th. — 
Pulse 140, feeble. Eespiration 40. Skin hot, bathed in profuse perspira- 
tion. Constant twitching of mouth, and lateral oscillation of the eyes. He 
has been in an entirely unconscious state for the last twenty-four hour's. 
Died at 3 p.m. He rallied from his insensibility a few minutes before death. 
Sectio cadaveris. — Body moderately nourished. Slight oedema of right 
leg below the knee. No bedsores. Only the spinal cord and bi'ain were 
examined. The spinal membranes were generally very full of blood, but 
especially on the posterior surface of the cord, and about the lumbar 
enlargement and the cauda equina. The whole cord appeared to be rather 
small. The adhesions between the two surfaces of the arachnoid were more 
than usually abundant, and on the j)osterior surface of the lumbar medulla 
the two layers of arachnoid and the pia mater were matted together by fine 
cellular adhesions. At several points the dura mater was much thickened 
and vascular. The substance of the cord was generally soft, the greatest 
softening being at the lumbar enlargement, which was of a dull chocolate 
colour and infiltrated with granular cells. Many of the capillaries (veins) 
were in-egularly dilated, and encrusted with oil-globules. The softening 
and infiltration extended along the posterior columns, which, examined 
microscopically, were found to be extensively disorganised. The focus of 
these changes in the cord was the lumbar enlargement and the posterior 
columns in the lower dorsal region, but even in the cervical segments, espe- 
cially in the posterior columns, there were found a few granule cells and 
scattered or iiTegularly aggregated oil- globules, proving that the whole 
length of the cord was more or less implicated in the pathological changes. 
In the arachnoid of the lower half of the cord were many white fibroid 
plates and opaque granules, not unlike miliary tubercles, but smaller and 

13 



194 DISEASES OF THE NERVOUS SYSTEM. 

less transparent. In the posterior columns, where the granule cells were 
most abundant, the capillary vessels were large, irregularly dilated, and 
encrusted with oil. The veins of the surface of the brain were distended 
with dark blood (death by asphyxia). There was a large excess of fluid 
under the arachnoid. This membrane was mottled with fatty deposits. 
The lateral ventricles large, containing about six drachms of clear fluid. In 
the centre of the right optic thalamus there was an irregular cavity, its 
surface lined by dilated capillai-y veins full of blood, and a soft flocculent 
tissue, containing oil-globules and granule cells ; the whole of a dull ash 
colour, without any tinge of blood-pigment, and due to advancing ulcerative 
absorption of the tissue. The surrounding brain substance had a " worm- 
eaten " appearance, and presented all the stages of decay. At the origin of 
the third nerve, on the right side, the pia mater was much thickened, and 
infiltrated with old plastic matter, becoming fibrous and vascular, and con- 
taining in it degenerated nuclei, granule cells, and oil-globules. The trunk 
of the nerve was slightly enlarged and tough, and had a yellowish, semi- 
translucent appearance. Under the microscope it was seen to be converted 
into a fibrous cord, with scarcely a trace of nerve-tubule. The substance of 
the crus beneath was healthy. The opposite nerve was normal. 

Remarks. — Dissipation, and the cacliexia resulting from 
syphilis and its treatment, were probably the predisposing 
causes in this case, which needed only the vicissitudes of our 
climate to give rise to chronic lesion of the cord. The severe 
neuralgic symptoms, supposed to be ordinary sciatica, which 
attended the invasion of the paralysis in the right leg, was 
probably due to venous congestion of the nerves of the cauda 
equina, which was remarkable in this case. In support of 
such an opinion, I may mention having found in other in- 
.stances varicose and enlarged venules in the trunks of neu- 
ralgic nerves. The diffused character of the lesion was in- 
dicated by the absence of any distinct horizontal line limit- 
ing the paralysis, the whole cord being in some degree 
implicated in the pathological process. The occurrence of 
ptosis, from thickening of the pia mater at the root of the 
third nerve, and the infiltration of the nerve-trunk with in- 
flammatory exudation, deserve notice, as associated with the 
changes in the spinal membranes. The ulcerative softening 
and destruction of the right thalamus may explain some cases 
of paraplegia complicated with amaurosis. The mode of 
death by subarachnoid and ventricular effusion corresponded 
to the chronic inflammatory changes in the spinal mem- 
branes. 



CASES OF PAEAPLEGIA. 195 



Case 13. — Acute faraplegia ; softening of cord ; fatty degeneration of the 
intervertebral substance ; fibrous plates on arachnoid. 

Mrs. G — , vei. ^^, wife of a honse-painter ; mother of one child, and now 
ten weeks pregnant with a second. Up to the time of this illness always 
had good health, though apparently of rather a delicate constitution. Com- 
plexion fair. Ahout midday on Monday, January 12th, 1855, whilst engaged 
in her domestic duties, she was suddenly seized with severe pain in the back, 
making her feel sick and faint. This lasted for half an hour, and then 
entirely left her. In the afternoon she went out, carrying her child, and 
returned home, feeling as well as usual, except being fatigued, which she 
attributed to having a cold. The next day, after passing a good night, she 
went about her household work, feeling very well until noon, when almost 
suddenly she became paraplegic. There was complete loss of sensation as 
high as the waist, as well as of voluntaiy movement, and entire loss of 
control over the sphincters. She was admitted under the care of Dr. Barlow 
February 23rd, 1855. Since her seizure there has been a gradual retura of 
sensibility, and of some power over the right foot and ankle. There are 
several sloughs on the feet from the application of hot water, and much 
lai'ger ones at the lower pai't of the spine, and over the hips. The face is 
pale, expression anxious. Pulse 120. Respiration 28, performed by the 
diaphragm and the five upper ribs, the lower intercostals being paralysed. 
The spine is straight and free from any irregularity. No tenderness at any 
spot. The urine withdrawn by the catheter is acid ; sp. gr. 1025. On 
questioning her she denies having any feeling of constriction around the 
chest or abdomen, but complains of a slight sense of weight at the sternum. 
No distension of the abdomen. Liver extends two inches below the ribs. 
February 27th. — Her nights are restless. Continued hectic symptoms. 
Face now flushed. Tongue furred and dry. No headache. No delirium. 
Pupils rather contracted. Can move the right foot and ankle slightly. 
Left leg quite immoveable. Sensation perfect. Yesterday had a rigor, 
repeated at bedtime. March 3rd. — Sloughs on back and hips extending. 
No complaint of pain. Tongue dry and brown. Stiffness between the 
shoulders, and aching pains down the back of the arms. Occasional spas- 
modic twitchings in the left leg, otherwise both are motionless. Supposed 
diarrhoea due to the constant passage of semi-solid faeces through the para- 
lysed sphincter. 7th. — Great emaciation. Pulse 130. Respiration quickened. 
•Slight cough, imperfect from the paralysis of the lower intercostals. Muco- 
purulent expectoration. The passage of the urine and faeces can still be 
felt, but is quite involuntary. loth. — Rapid decline of strength. Upper 
part of the trunk and arms perspiring. Skin of lower extremities dry and 
harsh. The paralysis of motion remains as before. Sensation throughout the 
paralysed parts nearly perfect. The smallest point can be felt, and the 
distance between two points appreciated as in health ; yet the acuteness of 
the pain from pinching the skin is diminished. The symptoms were noted 
from day to day, but did not vaiy in any essential respect. She died on the 
1 8th. The pulse was imperceptible at the wrist for many hours before 



196 DISEASES OP THE NERVOUS SYSTEM. 

death. No delirium or incoherence throughout the whole course of the 
disease, which lasted nine weeks and three days. 

Sectio cadaveris. — Body much emaciated, with extensive sloughs, as 
described in the report. On removing the cord with its membranes from 
the canal, the parts were healthy, except a small amount of opaque, cheesy 
matter, oozing from the fifth intervertebral substance. The dura mater was 
healthy. The arachnoid was free from adhesions, and everywhere normal, 
with the exception of many ossific plates scattered over its visceral layer, 
especially about the cauda equina. The substance of the cord was much 
softened, from the tenth dorsal vertebra) upwards for six inches and a half. 
The posterior columns were diffluent, the anterior were continuous. The left 
column was more softened than the right. The lower section of the softened 
part, for about two inches, was of a dull pink colour, and the vessels of the 
grey matter much injected. There was no trace of efEused blood. Amongst 
the softened tissue of this part there were a few granule cells of various 
sizes, and here and there an exudation cell having the ordinary appearance ; 
but above and below this point, the columns, though soft, gave no traces of 
corpuscular exudation, the texture being simply loosened. The amount of 
exudation, even at the point of greatest softening, must have been small, as 
the cord was not sensibly swollen. No trace of plastic exudation on the 
membranes. On making a section of the bodies of the vertebrse, the inter- 
vertebral substance of the fifth, sixth, and seventh was found softened, and 
in part opaque, from fatty degeneration of the fibrous stroma, and the carti- 
lage cells. The degeneration was most advanced in the fifth intervertebral 
substance, where the adjacent portion of the bone was becoming absorbed, 
and the fibrous structure of the posterior common ligament had in part 
yielded, and allowed some of the debris of the intervertebral substance to be 
squeezed into the canal, and so to injure the cord. This was the yellow 
matter seen on removing the cord and its membranes, and at first supj^osed 
to be strumous exudation. The lungs were free from all traces of tubei'cle. 
The lower lobes in a state of reddish-grey consolidation, easily lacerable. 
The bronchial membrane injected and gi'anular, and covered with tenacious 
puriform mucus. Liver weighed four pounds avoirdupois ; tissue pale, 
fatty. Kidneys soft ; tissue coarse ; weight ten ounces avoirdupois. 
Mucous membi'ane of bladder inflamed. Sloughs extending through the 
anterior wall to the sheath of the rectus, and posteriorly destroying the 
vagina. The os uteri sloughing, and a small ovum, well formed, protruding. 
The mucous membrane of the small and large intestines much congested. 
In the stomach, at the larger curvature near the fundus, were several ulcers 
of the size of a sixpence, the black sloughs of the mucous membrane being 
still adherent. 

Remarks. — The exciting cause of the acute softening of 
the cord in this case was mechanical injury^ resulting from the 
giving way of the posterior common ligament, and the escape 
of the debris of the degenerated intervertebral substance 
into the canal. The sudden pain in the back, with sickness 



CASES OP PAEAPLEGIA. 197 

and faintness, felt by the patient on the day previous to the 
paralysis, probably depended upon this rupture. It was 
thought, when the canal was first opened, that the lesion of 
the intervertebral substance was due to scrofulous deposit ; 
but that opinion was not supported by a further examination. 
It appeared to be only a form of atrophy, leading to opacity 
and fatty degeneration of the texture. As it was but a small 
spot of the posterior surface of the intervertebral substance 
which was affected, there was no displacement of the bones. 
The recovery of sensation even whilst the case was progress- 
ing to a fatal termination is of interest, as bearing upon 
prognosis. The same is observed in hemiplegia, from 
softening or effusion of blood into the corpus striatum or 
thalamus opticus, the loss of sensation accompanying the 
injury to the nervous centres being after a few days re- 
covered, though in other respects the symptoms may have 
undergone no favorable change. The subject has also a 
further interest in reference to the physiology of the sensi- 
tive functions of the cord, especially, as it will be observed, 
that the posterior columns were broken down, and only the 
anterior continuous. The cause of death was exhaustion 
from the unusually extensive sloughing of the pelvic viscera, 
and of the skin over the sacrum. 

The amount of exudation into the cord was, as usual, very 
small, and except at the part principally affected, the tissue 
was simply loosened and oedematous. Some of the granular 
bodies seen under the microscope were formed by the 
aggregation of granular matter around broken nerve-tubules, 
others had the more common origin from degenerated exvida- 
tion corpuscles. Whether such a lesion as this, apart from 
the chronic disease of the surrounding structures, is remedi- 
able, is very doubtful ; but, as observed in the preceding 
case, we should expect less from the use of calomel than from 
those means which favour nutrition. 

Case 14. — Paraplegia preceded by symptoms of colic; sudden loss of 
power and sensation in the upp)er extremities ; partial recovery for 
some months ; relapse ; general and slight softening of the ivhole cord ; 
traces of inftainmatory exudation discovered in the cervical portion, 
and in the 'medulla oblongata. 
Many of the particulars of this case were collected for me by my friend 

Mr. Edmund Gallon. 



198 DISEASES OF THE NEEVOUS SYSTEM. 

Esther J — , set. 32, a stout, leucophlegmatic woman, a widow, never had 
robust health, and as a girl was subject to severe headaches, and at times to 
hysteria, and also to painful and irregular menstruation and palpitation. 
Had, according to her account, two attacks of pleurisy eight years ago, 
and soon after was in St. Thomas's Hospital for rheumatism. Eighteen 
months ago had symptoms of colic, attended with giddiness and slight 
mental confusion ; and about that time, on waking one morning, found she 
had lost to a great extent the power of motion and sensation in both upper 
extremities. The hearing became at the same time dull, and her memory 
impaired. She gradually recovered the use of the arms, and continued in her 
usual health (though not able to walk up and down stairs, and occasionally 
having difficulty in breathing) until two months ago, when she began to 
have pain in the back between the shoulders, increased difficulty of breathing, 
pains in the limbs, with formication in the fingers, and pain in the left side 
and abdomen. A fortnight after this aggravation of her symptoms the power 
of the upper extremities became again much impaired, the wrists dropped, and 
the hands became numb. The legs were less afEected ; she was able to stand, 
but not to rise from her seat without assistance. The loss of power was 
rather more marked on the left side than on the right. The sense of taste 
was lost. On admission into the hospital, August 22nd, 1855, the following 
note was made of her condition. Sensation in the left arm perfect as far as 
the elbow, below it is gradually lessened, and entirely lost in the fingers. The 
motion of the shoulder-joint unimpaired, but attended with pain in the back. 
Power of extending the elbow-joint very imperfect, wrists dropped. Right 
arm similarly but less afEected. Can move the legs in any direction in bed, 
but is not able to stand without support. No affection of sensation. Loss 
of taste. Complains of pain in the back, passing over the shoulders. 
Tenderness on pressure over the lower part of the cervical, and upper part of 
the dorsal region. No abnormal condition of the spine discoverable. 
Severe griping pains in abdomen. Obstinate constipation. Dyspnoea, 
cough, and constriction across the chest, with inability to expectorate. 
Slight bronchial rales, respiratory sounds otherwise normal. Power to 
empty the bladder remains. Urine acid, high-coloured. Frequent cold 
perspirations, followed by flushing heats. Sleeplessness, despondency, 
globus, and other hysterical symptoms. There was no marked change until 
September 9th ; she was very desponding, and often expressed a wish to die. 
Had day by day various nervous symptoms of an hysterical character. 
Bowels obstinately constipated, great pain in the abdomen. Slight traces 
of blue line on the gums, which, with her other symptoms and the dropping 
of the wrists, favoured an opinion of lead poisoning. The dyspncea, cough, 
and inability to expectorate, with a sense of suffocation, continued to distress 
her very much. On the 9th all the paralytic symptoms were in a few 
hours increased, with intense pain between the shoulders and across the 
chest. The urine was passed naturally. Pulse weak and frequent. On the 
nth she was universally paralysed. There was frequent cough with 
inability to expectorate, and an increased sense of suffocation. Cardiac 
sounds very feeble. Paralysis of the respiratory muscles gradually increased. 



CASES OF PARAPLEGIA. 199 

The larynx soon became involved. She was neither able to speak nor 
swallow, but remained perfectly sensible until her death at midday. 

Sedio cadaveris. — Body well developed and stout. No sloughs nor 
abrasions on the back. Integuments and internal organs generally con- 
gested from the mode of death. Cerebrum, cerebellum, crura cerebri, and 
pons Varolii healthy. Medulla oblongata softened. Under the microscope 
there was seen, here and there, an exudation cell amongst the loosened 
tubular structure. The spine and its membranes were healthy. The cord 
softer than usual throughout ; but it was only after examining many parts, 
that any trace of exudation was discovered, and that only in the cervical 
region. Without repeated examination this would have been overlooked, 
both in the medulla and in the cord. The viscera, including the kidneys 
and bladder, healthy, with the exception of recent congestion. 

Remarks. — The morbid anatomy of this case is of great 
interest as elucidating those recorded instances of para- 
plegia where no lesion of the cord was observed. It was 
only by great patience that the microscope discovered any 
traces of inflammatory exudation, but these, though slight 
in amount, were distinct and decisive. It is probable the 
paralysis was rather due to the arrest or perversion of the 
normal processes of nutrition than to the mere mechanical 
effects of the exudation. 

The early symptoms were vague, and thought by some to 
be hysterical, thus affording another proof that it is not in 
the symptoms themselves, taken individually, but in their 
course and grouping, that the true basis of the diagnosis lies. 

Whether the paralysis was the effect of lead, as was 
supposed from the traces of a blue line on the gums, the 
dropping of the wrists, and the colic and constipation, is 
doubtful, as the anaemic and icterode tinge of the surface 
and conjunctivae, so characteristic of lead poisoning, was 
wanting ; neither do the affections from lead take such a 
course to a fatal termination. The remarks on the obscurity 
of causation apply to this, as to most cases of softening. 

Case 15. — Paraplegia commencing by paralysis of the rigid arm, and 
referred to an injury of the hand; an undefined nuclear growth in 
the cervical region of the cord, and a similar degeneration of the grey 
matter throughout. 

Abraham C — , jet. 23, stoker on board a steamboat, of intemperate habits, 
but has had pretty good health. Has occasionally been in pugilistic 
encounters, and received many blows on the head and forehead, but the 



200 DISEASES OF THE NERVOUS SYSTEM. 

most severe was about five years ago, when he was struck unexpectedly by 
another man's fist on the side of the neck, near the articulation of the skull 
with the vertebral column. Since that, he has occasionally had difficulty in 
deglutition, particularly of fluids, which would be expelled through the 
nose. For the last year he has had a choking sensation, and, at times, 
difficult}' in passing water. He attributes the weakness of his right arm to 
a blow which he received on the back of the hand, eighteen months ago, by 
the falling of a piece of iron. This accident kept him from his work for six 
weeks, but the wound healed without any extension of inflammation up the 
arm. As he recovered, he noticed a want of power in the ring and little 
fingers, and the whole arm, from the shoulder, became wasted and weak. 
He continued to work with his left arm for three months longer; but about 
the beginning of the year 1850 he began to suifer from what he terms 
" bile," that is frequent vomiting, unattended by any pain in the head or 
giddiness. These returns of vomiting continued for four months, and then, 
as they subsided, there was increased difficulty of deglutition, and both legs 
became weak, tlie left first and to the greatest degree. In the autumn he 
improved, and was able to walk about, but the bladder was so far paralysed, 
that he needed the catheter to be passed for several weeks. The improve- 
ment was only of short duration. On his admission into Guy's, June 5th, 
1 85 1, under the care of my colleague, Dr. Barlow, the right arm was com- 
pletely paralysed at the shoulder-joint, and there was great wasting of the 
muscles, only slight power of moving the fingers remained. There was 
anaesthesia increasing towards the hand, most marked in the branches of 
the ulnar nerve. No actual paralysis of the left arm, but the muscles 
flaccid and weak. He had pains running over the back of the head. He 
could move the legs slightly. Sensation impaired as high as the hips. No 
deformity of the spine, nor tenderness on percussion. No sense of constric- 
tion at any part of the trunk. Vision somewhat impaired. Urine and 
fgeces often passed involuntarily. Pulse 90. Tongue clean and pale. He 
improved, by rest and by the use of electricity, so far that in October, he 
could support himself and walk without help, though the gait was veiy 
vacillating, from want of power to direct the muscles. No numbness 
remained in the legs. The right arm continued in the same state as on 
admission. The left was (veak, and at times he had cramp in the muscles, 
and involuntary closure of the hand. The sphincters partially paralysed. 
Aspect pale and emaciated ; the whole muscular system much atrophied. 
He continued in the hospital until June, 1852, his symptoms fluctuating 
between improvement and relapse. He could walk about the ward, by the 
aid of a stick, with a feeble gait, his right arm hanging loosely, supported 
only by the ligaments of the shoulder-joint. On leaving the hospital he 
went to Dover, but returned, and was readmitted in October, 1852. In a 
few weeks the left arm was quite paralysed, and he lost the little remaining 
power over the logs and sphincters, and became universally paraplegic. He 
often complained of a sharp pain in the back of the head and in the upper 
part of the neck. On 19th January, 1853, bronchitis came on from ex- 
posure in moving him from one ward to another ; though trifling in 
amount, the distress occasioned by it was inexpressible, from the paralysis 



CASES OF PARAPLEGIA. 20l 

of the intercostals. A remission of his chest symptoms occurred until 
March 14th, when they again hecame aggravated. His distress was in- 
describable. Constant ineffectual efforts to expectorate; pulse rapid, 120 ; 
respiration 36 ; face congested ; complete paralysis of the extremities and 
walls of the chest, and general anaesthesia, yet great pain when the body or 
limbs were roughly handled ; frequent spasms in the legs ; arms not so 
affected. Urine constantly dribbling. Slight abrasion of the skin over 
the sacrum, but no sloughs occurred throughout his illness. His miser- 
able existence was drawn out until April 12th, 1853. 

Sectio cadaveris. — Remarkable atrophy of the whole muscular system, 
and of the tissues generally. Slight abrasion of the skin over the promi- 
nent pai't of the sacrum. No slough. Diffused tubercular masses and 
scattered tubercles through the upper lobes of both lungs. Dilatation of 
the bronchial tubes ; their lining deeply injected. Contents purulent. 
Heart healthy. Hepatic tissue congested and fatty. Kidneys healthy. 
Pia mater and brain tissue rather watery. On removing the arches of the 
vertebrse the whole cord appeared to be large and swollen ; in the cervical 
region the theca was evidently distended by it. There was no affection of 
the bones or ligaments. On laying open the theca there was a general 
enlargement of the cervical portion of the cord, which, on transverse sec- 
tion, had an unusual appearance. The columns had a yellowish tint, and 
were distended by a soft vascular translucent growth, parts of which were 
firmer and opaque yellow (dead?). This growth was not defined, but passed 
insensibly into the degenerated grey matter (Plate I, figs. 3 — 6), which 
from the floor of the fourth ventricle to the filum terminale was pale 
and swollen, and had much the physical character and consistence of thick 
boiled starch. This soft starch-like substance under the microscope was 
seen to consist of round, oval, and elongated granular nuclei, embedded in a 
slimy blastema. At the filum terminale, where the more normal characters 
of the grey matter were preserved, these nuclei were scattered amongst 
the softened tubercles with exudation cells. The vascular growth in the 
cervical region consisted of degenerated nervous tissue, nuclei, and nucleated 
cells, as in the fibro-plastic growths. The opaque part was little else than 
granular matter and oil-globules. There was no lesion of the membranes 
of the cord, nor was the continuity of the columns destroyed, though in the 
cervical region they were spread out and slightly softened in parts. The 
nerves arising from the cord in the cervical and lumbar regions, examined 
microscopically, had the normal structure. 

Remarks. — The limitation of the paralysis at its com- 
mencement to the right arm, and the preponderating 
affection of the muscles of the shoulder-joint, are points in 
the history of this case of great interest. Taken together 
with the injury to the hand, to which the patient attributed 
his symptoms, they led to an opinion that the case was one 
of peripheral paralysis, but such an inference was not 



202 DISEASES OF THE NERVOUS SYSTEM. 

supported by the history of the case, nor by the post-mortem 
appearances o£ the cord. The slight affection of the 
muscles of deglutition, the sense of choking, and the 
occasional loss of power over the bladder, connected the 
blow at the upper part of the spine with the lesion in the 
cord, whilst the peripheral origin of the malady was entirely 
negatived by the normal microscopic structure of the nerve- 
trunks. The general atrophy of the muscles of the extremi- 
ties in the progress of the case before the more distinct 
symptoms of paralysis occurred is deserving of special note, 
as bearing upon the theory of progressive muscular atrophy, 
many examples of which have no doubt had, contrary to the 
opinion of those who recorded them, a spinal rather than a 
muscular origin. The atrophy of the muscles of the right 
shoulder, whilst those of the forearm still retained some 
power, elucidates the seat of the paralysing lesion in some 
cases of infantile paralysis of the shoulder occurring during 
dentition. It has been doubted whether the lesions alluded 
to have a cerebral or a spinal origin, but their occurrence 
"without any cerebral symptoms, the occasional affection of 
both arms or of all the extremities, and the actual observa- 
tion of a limited spot of ochrey discoloration in the cord, 
as in one case examined by Cruveilhier, concur with the 
collateral evidence here afforded in proving a spinal origin 
of this form of paralysis. There is nothing in practical 
medicine more fallacious than hastily inferring a negative 
from negative evidence, as was proved in this case. The 
absence of pain on percussing the spine, and the positive 
account given by the patient that his paralytic symptoms 
were the result of the injury to the hand, led to the con- 
clusion that no lesion of an active kind was going on in the 
cord, yet we can have no doubt that the contrary was the 
fact. The least consideration will show that if the liga- 
ments and bones be healthy, no amount of pressure or 
percussion made in the usual way of a clinical examination 
can much affect the structure of the cord itself, and that we 
can base no inference upon the negative evidence so afforded. 
There is a minor symptom in this case deserving of notice ; 
I allude to the impairment of vision. This may be asso- 
ciated from different causes with paraplegia. Here it was 



CASES OF PARAPLEGIA. 203 

probably referable to the changes in the cervical portion of 
the cord itself, since it has been clearly shown by experi- 
ments on animals that the condition of the eye is at once 
affected by injuries to the roots of the cervical nerves. I 
have had occasion to notice this in preceding cases. 

Vomiting, as an early symptom of disease of the cervical 
portion of the cord, occurred in this case, and was probably 
dependent upon the origin and connection of the phrenic 
nerves ; in another case, as we have seen, the symptoms set 
in with an irritating cough. I remember an obstinate case of 
hiccup, which, having resisted other treatment, yielded at 
once to blisters on either side of the cervical portion of the 
spine, over the origin of the phrenic nerves. The character 
of the local changes in the grey matter was peculiar, and 
probably depended partly upon degeneration of the normal 
structure, and partly on a neoplastic formation of the 
simplest kind. In the cervical region, where the disease 
first commenced, this had progressed to the greatest extent, 
making an approach to the development of a tumour, but 
not separated by any line of demarcation from the other 
parts of the grey matter which had undergone a similar, 
but less advanced, change. The existence of tubercles in 
the pulmonary tissue can hardly, in cases like this, where 
young persons have been long bedridden, be regarded as an 
index of a previous scrofulous habit, since it is more than 
probable, at least in some of the cases, that the tubercular 
diathesis was induced by the unfavorable circumstances to 
which they were subjected. 

Case i6. — Paraplegia; early sym2)toms referred to rlieumatisvi and 
phthisis; induration of the cord at the cervical enlargement ; soften- 
ing of the dorsal segments adjacent. 

For the following case I am indebted to my friend Mr. Bradley, who also 
kindly sent me the cord for examination. The patient was an inmate of 
the Model Prison. 

W. P — , ffit. 29, a single man, native of Devon, employed as a shejAei'd, 
of healthy appearance and florid complexion. His health had always been 
good previous to the 25th of January, 1850, when he began to complain of 
pains which he attributed to having caught cold in a bath some days before. 
These pains at first occupied the left shoulder, particularly the scapula and 
the deltoid, but subsequently extended down the arm to the fingers, and at 
times wandered into the leg of the same side. From the description given 



204 DISEASES OF THE NERVOUS SYSTEM. 

of the pains, and from the absence of other symptoms, either local or 
general, the case was regarded as rheumatalgia. During a period of two 
months various remedies were in turn prescribed, but without any satisfac- 
tory result. The only one that afforded any relief was morphia. By this 
time the pain was localised in the shoulder-blade, and though not paroxysmal, 
yet, from its severity, it appeared to be neuralgic. Symptoms of phthisis 
also now began to show themselves. There was great emaciation and mus- 
cular debility. Pulse 120 and weak. Profuse nocturnal sweats, especially 
about the head and chest. Dry cough. Chest everywhere resonant ; 
respiratory murmur at the left apex impaired. Constipation. By the 7th 
of April the weakness of the lower extremities had increased, so that he was 
unable to stand. There was imperfect control over the sphincter ani, and 
the urine was retained. That drawn off by the catheter was clear and 
faintly alkaline. On the 8th the urine was ammoniacal. Motions passed 
unconsciously. Voluntary movement of lower extremities lost. Sensation 
impaired from fourth rib downwards. Upper extremities unaffected. In- 
tellect unimpaired. No tenderness on percussing the spinal column. Appe- 
tite nnimpaired. Sleep sound. No complaint of pain. The treatment 
consisted in the exhibition of calomel in grain doses to affect the system. 
Blisters, with mercurial dressing, to the lower portion of the cervical region 
of the spine, and between the scapulae. On the i8th his condition was 
much the same as on the 8th, except that sensation in the lower extremities 
was improved. There were cramps and flying pains in the limbs, with 
spasmodic movements of the muscles of the upper extremities. The per- 
spirations were profuse. Gums affected by mercury. May ist. — A seton 
was inserted on both sides of the spine, at the nucha. On the 13th the 
cough and expectoration had ceased. Sensation had returned in the legs ; 
he could retain his motions, and was conscious of the passage of the urine. 
On the 23rd the setons were removed, and, as he complained that the 
involuntary spasms of the limbs prevented sleep, he was ordered half a 
grain of morphia every night. On June 3rd he had lost power in his hands, 
and thei'e was loss of sensation in the ulnar side of the right hand and back 
of the arm. The paralysis of the lower extremities continued, but sensation 
was restored, and he could retain the urine and fseces. Subsequently the 
pain and spasms of the lower extremities were very distressing, and he 
complained of pain about the third and fourth dorsal vertebrjB, increased by 
percussion. On the 20th bronchitis set in, attended with great difficulty in 
expectoration. He gradually sank on the 29th. 

Sectio cadaveris. — Body greatly emaciated. Brain and its membranes 
healthy. Membranes of the cord healthy. At the cervical enlargement 
the cord was indurated to the extent of an inch. On section at this point 
the columns had a greenish-yellow tint, and were of an almost horny hard- 
ness ; below this part, for three or four inches, there was marked softening, 
the columns being nearly diffluent. Kidneys large, pelves and ureters 
dilated. Abdominal viscera healthy. Recent pleuro-pneumonia at the 
bases of both lungs. The apices adherent, the pulmonary tissue indurated, 
and containing several small vomicae (?). Bronchial tubes generally dilated, 
and containing muco-purulent secretion. 



CASES OF PAEAPLEGIA. 205 

Remarks. — I have to regret that a microscopical exami- 
nation was not made of the indurated portion of the cord in 
this case. The induration was uniform, and the cord some- 
what swollen, as if from fibrinous infiltration of its textures. 
The chief clinical interest of the case was the obscurity of 
its early symptoms. For a period of two months pains, 
supposed to be rheumatic or neuralgia, were the only com- 
plaint, and it was even suspected that the patient, under 
the circumstances, might be feigning illness. The next 
phase was great muscular debility, rapid emaciation, dry 
cough, and profuse sweats. As the chest was resonant 
throughout, the patient was supposed to be labouring under 
diffused tubercular disease of the lungs, though there can 
be no doubt the symptoms had, as in a previous case (Case i), 
a spinal origin. It was not until imperfect control over the 
sphincters roused attention that the spinal disease was 
suspected. It will be observed that after the first shock of 
the onset of the more marked paralytic symptoms sensation 
slowly returned, as in a previous case. The spinal mem- 
branes were healthy, yet it will be observed that the early 
symptoms were pain, radiating in the course of the nerve- 
trunks, and as the paraplegia became more marked the 
patient was greatly distressed by painful spasmodic contrac- 
tions of the legs. There was no account in the history of 
the case of the exciting cause of the malady. 



PLATE I. 

Fig. I. — A vascular fibro-nuclear tumour growing from the inner surface 
of the dura mater on the anterior part of the cord in the upper part of the 
dorsal region: the cord pushed backwards and compressed (Case 2, p. 170). 

Fig. 2. — A vascular fibro-plastic tumour, situate on the posterior surface 
of the cord in the lower part of the dorsal region under the close arachnoid 
(Case 3, p. 172). 

Figs. 3 — 6. — Sections of the cord in Case 15, p. 199, showing the enlarge- 
ment (6) in the cervical region from the development of a soft vascular 
nuclear growth in the grey matter. The sections 5, 4, 3, are intended to 
show the same in a less degree in the other parts of the cord lower down. 




Platte 1 



Piq 3 



Pig 1, 



Fiq 2. 



^ 




f i q 4: 




4a 
T19 5 



Fag 6 



"WesVTMewinaTi Hth. 



CASES or PAEAPLEGIA.^ 

(SECOND SERIES.) 



The following cases of paraplegia, with those in the 
'Reports' for 1856, though a miscellaneous contribution, 
may perhaps serve for reference in the absence of a more 
systematic treatise on the subject. 

The labours of Lockhart Clarke and Lenhossek, on the 
minute structure of the nervous centres in health, cannot 
fail to give a new impulse to a more exact knowledge of the 
pathological changes to which they are subject. Something 
in this direction has been attempted. Those who are 
acquainted with the results of minute anatomy, as applied 
to the cord, will admit that we may now hope for an 
exhaustive morbid anatomy of it, exhaustive, at least, so far 
as to enable us to determine the state of the ultimate tissue. 

Case 17 goes far to establish an important point in the 
pathology of paraplegia, namely, that the spinal centi-es may 
be paralysed without anatomical change of their structure. 
If this were certain it could not fail to give a new direction 
to our inquiries, and lead us with more earnestness to 
investigate the nervous substance by other means than the 
microscope. Dr. Sankey's observation on the variable 
specific gravity of the brain, lets in some light in this direc- 
tion. It is from an increased knowledge of " atomical,'' as 
distinguished from " anatomical " conditions, that we may 
hope for future advances in nervous pathology. 

Case 18 presents a not uncommon history of chronic 
inflammatory degeneration of the columns of the cord almost 
^ Reprinted from the 'Guy's Hospital Reports,' 1858, p. 169. 



208 DISEASES OF THE NERVOUS SYSTEM. 

latent up to a certain point, and then accompanied by a 
sudden aggravation of the symptoms. It may offer an 
occasion to remark that in diseases of the nerve-substance, 
acuteness of effects is no evidence of acuteness of the lesion 
producing them. In the brain this is notoriously true, for 
every one knows that a sudden hemiplegia may result from 
local changes of the slowest and most passive kind. The 
same occasionally occurs in tlie cord. The bearing of this 
on diagnosis and treatment is obvious. 

Case 19 is a remarkable instance of the limitation of 
disease to the posterior columns. The lesion was of the 
same character as in the preceding case. The symptoms 
confirm the theory of Dr. Todd that the posterior columns 
are the channels through which the voluntary movements 
are co-ordinated. In this case there was not paralysis, but 
a want of controlling power. There was only a slight 
affection of sensation, proving also that the posterior 
columns are not mainly subservient to the sensory function. 

Case 20 presented at the bedside a rare symptom in 
paraplegia, namely, paralysis of both seventh nerves. This 
prevented the pronunciation of the labial parts of speech, 
and led to a suspicion of brain disease until the kind of 
defect was pointed out. This accident was explained by the 
condition of the medulla oblongata. 

As it has been jast remarked, on the one hand, that the 
character of a lesion of the nervous substance is not to be 
inferred from the acuteness of the symptoms in respect to 
their development in time, so it may be added, on the other, 
that the amount of the lesion is not necessarily in proportion 
to the gravity of the symptoms. A very small amount of 
anatomical disease, or, as we seem to have proved in Case 
17, not enough to be recognised, may produce fatal effects. 
The degree of positive lesion was appreciable in this case, 
but it was in amount trifling. It was its seat which gave it 
its importance. It is in the treatment that we need to bear 
these truths in mind, as no doubt there is a proneness in 
the mind, as before said, to estimate the activity and violence 
of a disease by the rapid development and danger of the 
symptoms, and, consequently, to aggravate it by too heroical 
interference. 



CASES OF PAEAPLEGIA. 209 

In Case 21 the limitation of the disease at its onset to the 
right side of the cord, and the suddenness of the early 
symptoms are the chief points of pathological interest. 

The occurrence of erysipelatous inflammation from the 
incautious application of heat, is an accident to which para- 
plegic patients are notoriously exposed. 

It does not seem unimportant to draw attention to the 
difference between capillaries mechanically incrusted with 
fat-globules as the result of disease of the tissue in which 
they lie, and that form of fatty degeneration which is pre- 
cursory of atrophy. 

Case 22 shows that the substance of the cord may be 
damaged by a violent exertion, without any affection of the 
bones, ligaments, or membranes of the spine. Whilst such 
injuries have an immediate interest to the surgeon they 
have not less a deferred interest to the physician, who is 
often called upon to treat the subsequent effects. It is on 
this account that I have recorded this case and Cases 23 
and 24. In Case 23 there was bruising and ecchymosis of 
the posterior columns and of the grey matter, followed by 
hypereesthesia of the parts below. In Case 24 there was 
first paraplegia from concussion of the cord, recovery after 
a few hours, and subsequently fatal paraplegia from ex- 
travasation of blood outside the theca vertebralis along the 
spinal canal. 

Cases 25 and 26 are instances of progressive muscular 
atrophy from chronic disease of the cord. The early sym- 
ptoms of such cases are like those which come on in lead- 
poisoning. The wrists drop and the hands become weak. 
It seems hardly necessary to assert that such symptoms are 
not pathognomonic of the presence of lead, as some have 
stated, for it must be obvious to anyone who will consider 
the matter that in chronic affections of the cord in the 
cervical region the disease is not always so uniform in its 
seat and extension as to affect the muscles in the same 
order. In one case the arms may waste generally and 
equally throughout ; in another, the scapular muscles and 
those of the shoulder may be first affected ; and in a third, 
the interossei of the fingers, the short muscles of the thumbs 
and the extensors of the wrists may first fail. The relation 

14 



210 DISEASES OP THE NERVOUS SYSTEM. 

of the nerves of the brachial plexus to the cervical enlarge- 
ment of the cord, partly explains these differences, and what 
remains obscure seems to require for its elucidation only a 
more accurate investigation of the distribution of the lesion 
through the cord in particular instances. 

Cases 27 and 28 are recorded for the purpose of pointing 
out the occurrence of acute rheumatic symptoms after spinal 
lesions. Mere pain in the joints and limbs, generally, is 
not what is here meant. It is too common an error to 
account for obscure pains by calling them " rheumatic,'^ to 
need any remark. The symptoms referred to are commonly 
regarded as pathognomonic of a rheumatic state, namely, 
swelling and redness of the joints ; profuse acid sweats ; 
high-coloured, scanty urine depositing urates, &c. Our 
ignorance of the essential nature of acute rheumatism 
prevents our asserting or denying that it may have its origin 
in a disturbance of the nervous force, but certainly a con- 
dition apt to be confounded with it does so arise. In 
practice it cannot be an indiiferent matter, whether, 
according to popular pathology, we set before us, as the 
object of our treatment, the elimination of a materies morbi 
or a lesion of the nervous centres. 

Case 29 is remarkable for its clinical history, and the 
apparent contradictions which misled the diagnosis for the 
first two or three years. It was a case of chronic thickening 
of the spinal membranes implicating and destroying the 
posterior roots of the nerves of the brachial plexus. The 
disease was for some time so limited as to produce no other 
symptom than numbness of the left arm. 

The test by galvanism, proposed by Ducheune, was entirely 
fallacious. This excellent author, in a resume of his deduc- 
tions on what he terms " faradisation " (electro-magnetism), 
applied to pathology, gives the following conclusions in 
respect to hysteric paralysis:^ — i. Electro-muscular con- 
tractility is normal in hysterical paralysis. 2. Electro- 
muscular sensibility is, on the contrary, generally diminished 
or altogether absent. 3. Lastly, voluntary movements may 
be intact notwithstanding the diminution or loss of the 
electro-muscular sensibility. 

' ' De I'Electrisation localisce,' p. 530. 



CASES OF PARAPLEGIA. 211 

All these conditions concurred in this case, and yet it 
was one of organic lesion of a serious kind. 

The case affords a striking proof of the insidious origin 
and course of chronic spinal meningitis. The local action 
appears never to have been acute, and was unattended by 
those symptoms of irritation which are supposed to cha- 
racterise inflammation of the membranes of the cord. 

The changes in the cord were probably subsequent to 
those in the membranes and posterior roots of the nerves. 

Cases 30 and 31 are good examples of malignant disease 
about the spine affecting the cord. In one the substance of 
the cord was sloughing ; in the other the proximity of the 
cancerous growth had induced only softening. In neither 
was the nervous substance the seat of the new growth. 
At an early period, when there is nothing tangible, the 
symptoms in such cases are commonly referred to neuralgia ; 
the word " neuralgic," for explaining symptoms, as the 
word " idiopathic, ^^ for explaining causes, being of so easy 
use that it invites careless investigation. But, for this, 
there are generally circumstances which would suffice for a 
sound diagnosis. The pain is more or less characteristic in 
its continuance and severity. Its seat about the spine is 
also a sufficient cause of suspicion, since this region is not 
commonly affected with pure neuralgia; added to which, 
collateral symptoms, if sought for, are often found to 
remove the difficulty. For instance, signs of pressure on 
the bronchi, where the dorsal region is the seat of the 
disease, or, as in Case 30, the invasion of an adjacent organ 
by the malignant growth. 

Case 31 is one of strumous tubercle developed towards 
the centre of the cord. The chief value of the case lies in 
its history, for the patient being an infant, as the arms only 
were at first affected, the paralysis might not have been 
regarded as of serious importance. Young infants are 
occasionally the subjects of paralysis of one or both arms, 
from the carelessness of nurses in tying the dress so as to 
produce pressure on the axillary plexus. Not unfrequently 
also the paralysis of the period of dentition, the " paralysie 
essentielle " of French authors, shows itself in one or both 
arms, whilst the legs remain unaffected. In both these 



212 DISEASES OF THE NEEVOUS SYSTEM. 

forms the onset of the paralysis is sudden, and by that alone 
they would be distinguishable from such a case as the 
above. 

Case 17. — Complete paraplegia without loss of sensation; onset of sym- 
ptoms sudden. Death after fourteen days from acute peritonitis set 
up by inflammation of the bladder ; no discoverable change in the 
structure of the cord beyond slight softening of the texture ; no 
exudation. 

(Reported by Mr. Dueham.) 

Heniy P — , set. 32, clerk to a solicitor in the City, was admitted under 
my care into Guy's Hospital, 23rd December, 1857. ^ ^^^^' well-made, 
rather pallid, but otherwise healthy-looking man, suffering from entire 
paraplegia of the lower extremities and sphincters, but without affection of 
sensation. He stated that he had never previously had any serious illness, 
but that two years ago he fell whilst attempting to jump over some chairs. 
After a few days all apparent effects of this accident passed away, and he 
considered himself in unimpaired health. In the summer of 1857 ^^ 
manied, and gave liimself to excessive indulgence in sexual intercourse. 
He was otherwise temperate. For two or three months preceding the 
sudden development of the paraplegia, he experienced at times some 
diflficulty in micturition. The urethra was healthy. On the 9th of 
December there was numbness of the lower extremities extending as high 
as the knees, but this was so slight as not to attract any attention at the 
time. On Monday, the 14th, he walked as usual from the suburbs to his 
business in the City. About the middle of the day, as he was crossing his 
room, his legs suddenly became weak, and he would have fallen had he not 
heen supported. After a short time he recovered sufficiently to walk with 
some difficulty to the omnibus, and afterwards from the omnibus to his 
home. In the course of the afternoon he became entirely paraplegic, 
the urine and faeces passing involuntarily from him. There was no 
affection of the upper extremities except slight and transient formication in 
the hands. 

On admission, on the 23rd, there was only a trace of excito-motor activity 
in the left leg, and none in the right. There was no appreciable dimi- 
nution of sensation. Movements in the chest normal. Pulse 120, feeble. 
Pupils dilated. Surface of trunk and upper extremities warm and per- 
spiring. Legs cold. A sense of tightness around the chest, about the 
attachment of the diaphragm. Bowels inactive. Urine, drawn off by 
catheter, acid. 

The day following his admission there was noticed to be some oedema of 
the integuments in the lumbar region, especially on the right side. On the 
26th this had almost disappeared. The spine was normal. No change in 
the paralytic symptoms. Occasional slight involuntary twitchings of the 
legs. Electro-contractility of the muscles good. Only the slightest trace 
of excito-motor action, and that limited to the left leg. The integuments 



CASES OP PARAPLEGIA. 213 

over the sacrum reddened. Pulse 130. Skin hot and dry. Urine am- 
moniacal, and containing a large quantity of very offensive mucoid pus. 
The passage of the catheter was followed by much bleeding. During the night 
of the 28th nausea and vomiting came on, with great prostration. Respira- 
tion thoracic. Death from exhaustion on the morning of the 30th, the case 
having been brought to a rapid termination by the supervention of acute 
peritonitis upon inflammation of the bladder. The upper extremities were 
unaffected throughout, with the exception of the slight and transient formi- 
cation noticed above. 

Post-mortem examination. — Head not examined. About the base of 
both lungs, commencing acute lobular pneumonia. Lung tissue otherwise 
healthy. Heart healthy. Intestines covered by recent inflammatory exuda- 
tion. Mucous membrane of bladder sloughing. Its muscular coat, and the 
pelvic areolar tissue, infiltrated with fetid pus and urine. Two false 
passages, one passing through the prostate and thence into the bladder, 
and the other passing into the areolar tissue behind it. No stricture of 
the urethra. Texture of kidneys healthy. No trace of old or chronic 
disease could be discovered, either about the pelvis, in the pelvic viscera, or 
in the bodies of the vertebrae. The larger veins were opened, but afforded 
no evidence of phlebitis. Integuments over the sacrum beginning to slough, 
over the lumbar region they were cedematous. Membranes of the cord 
healthy. As the finger was passed lightly along the body of the coi'd it 
appeared to be somewhat softened at two points, in the middle, and at the 
lower part of the dorsal region ; but on the most careful microscopical 
observation nothing abnormal was discovered in the texture either at these 
pai-ts or in any other, though the cord was submitted to repeated and 
searching examination by the microscope. The epithelium lining the 
ventricle of the cord in the lower dorsal and lumbar regions was abundant, 
but normal. A few granules of brain-sand were found in the posterior 
columns, about the middle of the dorsal region. No traces of inflammatory 
exudation anywhere, either in the cord or in its membranes, nor any evidence 
of degeneration of the nerve-tubules. 

Remarl's. — When this patient came under care it was 
thought that the paraplegia was the result of ramollissement 
of the substance of the cord, which had (as not unusually 
happens) been more or less latent in its progress, the sudden 
paraplegia coming on when the conducting tubules have 
reached a point of degeneration which destroys their con- 
tinuity. The examination of the cord did not confirm this 
diagnosis. In the present state of nervous pathology the 
case remains unexplained. It is confessedly difficult to 
establish a negative, but the difficulty was met with unusual 
care in this case. Hours were spent in the examination of 
the cord, but with no other result than to show that there 



214 DISEASES OF THE NERVOUS SYSTEM. 

was no appreciable lesion of it besides a slight and doubtful 
softness of the tissue at two points. We may, therefore, 
certainly conclude that the spinal cord may have its func- 
tions impaired and even lost, and that suddenly, as far as 
the power of motion is concerned, without any distinct 
amount of anatomical lesion. Some writers have thought 
that the cord might be paralysed by a morbid impression 
made upon it, through incident nerves, and independently 
of any lesion of structure. Mr. Stanley sought to establish 
this in reference to disease of the kidneys, believing that 
these organs when congested might, through their nervous 
connections, set up paraplegia. I have shown in another 
place (' Med. -Chir. Trans. ,^ 1854) that the cases recorded by 
that author do not support his theory. In the instance 
before us there was no lesion of the kidneys or of the pelvic 
viscera preceding the paraplegia ; nor does there in the 
history of the case appear to be any sufficient cause for the 
paralysis, unless we accept it as one of acute tabes dorsalis, 
resulting from over sexual indulgence. Had the case not 
been rapidly terminated by cystitis and acute peritonitis, the 
cord, examined at a more advanced pei'iod, would, in all 
probability, have presented definite degenerative changes ; 
or perhaps it might have recovered itself by the slow pro- 
cesses of nutrition. It is worthy of notice that sensation 
was not affected. In the treatment, cupping, blisters, and 
mercury would have been obviously inappropriate. Wine 
and opium moderately in the beginning, and at a later 
stage the mineral tonics, were the means indicated ; but 
unfortunately, as too often happens, the accidents of the 
paraplegia, the pelvic complications, gave no opportunity 
for the successful issue of the case. In this respect women 
have the advantage over men, catheterism being less needed, 
or when required, less liable to produce injury in them than 
in the male sex. 



Case 18 (Plate II, fig. i). — Numbness and weakness of legs for several 
months ; sudden onset of fain and increased debility ; no impairment 
of sensation ; temporary increase of voluntary power under the use of 
strychnia, soon followed by complete paraplegia; retro -peritoneal 
abscess between bladder and uterus ; death from peritonitis ; remark- 



CASES OF PARAPLEGIA. 215 

able atrophy of the grey substance of the coi'd ; chronic inflammatoi'y 
degeneration of the posterior columns. 

(Reported by Mr. Dueham.) 

Harriet B— , set. 50 (?), but looking much older. A widow employed as 
a nurse. Admitted into the hospital loth December, 1857. Seven weeks 
before this she was suddenly seized with acute pain in tlie right foot, so 
severe that she could not move the leg In a few days the left foot was 
similarly affected. The pain gradually subsided, but only to return at 
intervals as severely as ever. The muscular power became at the same time 
impaired. She could move the limbs when lying down, but not leave her 
bed. On questioning her it appeared she had for some time felt uncomfort- 
able sensations in the legs, with slight numbness, and a feeling of debility, 
but was able to perform her duties until the time of the sudden seizure of 
pain. When she came into the hospital there was only just sufficient volun- 
tary power over the legs to flex them slightly, the left rather the most. 
Occasional feeble involuntary jactitations, and distinct but not very marked 
excito-motor movements. Sensation not impaired. Urine drawn off by 
catheter, ammoniacal and containing mucus. Pain over the abdomen ; 
occasional vomiting. Strychnia was given in doses of -^^ grain. Under its 
use the voluntary power was for a few days rapidly increased, but at the 
end of a week the spasms of the legs were so violent the medicine could not 
be continued. The cord was left exhausted, and, at the end of five weeks 
after her admission, the legs were completely paralysed, and no excito-motor 
movements could be produced. Sensation now seemed to be impaired, but 
the patient at this period of her illness lay for the most part in such a dull 
and stupid state that it was difficult to form a satisfactory opinion on certain 
points. The skin was abraded over the sacrum and trochanters. Highly 
offensive urine dribbled from the bladder. She would not submit to have 
anything done with the catheter, on account of the pain it caused her. 
She lay in a state of semi-coma, and died exhausted, February 5th, 1858. 

Post-mortem examination. — Body wasted. Head not examined. Spinal 
bones, ligaments, and theca vertebralis, healthy. Arachnoid normal, with 
one or two fibroid plates on the visceral layer. Spinal cord in the lower 
dorsal region small, and soft to the touch ; the anterior fissure gaped open. 
Examined in the fresh state, abundant granule masses (exudation cells, &c.), 
having the usual appearance, were found in the columns. On section, the 
centre of the cord formed an irregular depression from atrophy of the grey 
substance. These changes were, however, more definite after the cord was 
hardened by immersion in spirit and thin sections made of it. The atrophy 
affected the fibrous portion of the grey substance. The caudate vesicles 
had their normal position and structure. There was no exudation amongst 
the grey substance. The symmetry of the changes in the columns, and the 
mode of extension of chronic disease in them, are well shown in Plate II, 
fig. I. The lesion was due to chronic inflammation and concomitant atrophy 
of the tissue, with subsequent fatty degeneration of the newly effused matter. 
The fatty incrustation of the capillaries was a mechanical result, as shown in 
Case 21. Cortical portions of both kidneys full of points of suppuration. 



216 DISEASES OF THE NERVOUS SYSTEM. 

Pelves, uretei"s, and bladder, acutely inflamed. A large retro-peritoneal 
abscess between the bladder and uterus, but not communicating with the 
bladder. Kecent inflammatory effusion over several coils o£ intestines in 
the pelvis. Viscera of chest healthy. 

Remarks. — An inspection of the section given in Plate II, 
fig. I, will show^ liow mucli could be expected from treat- 
ment. It cannot be objected tliat the lesion there depicted 
does not convey a true impression of what existed during 
life, since there is no evidence of recent changes. It is an 
important consideration in the treatment of diseases of the 
nervous centres, how far the symptoms are due to irremedi- 
able changes or not. A lesion of the nervous tissue may be 
cured — or, at least, be in a state which, if it were in the 
skin or muscle or gland, would be called cured — and yet, 
according to the patient's estimation, the disease may remain. 
We too often think of symptoms as substantially the 
disease ; and if this false view guides our treatment we 
cannot fail of doing harm. We waste the feeble powers of 
an already partially dilapidated system, instead of recog- 
nising the dilapidation as an essential and permanent condi- 
tion of the body we have to treat. 

The therapeutical agency of strychnia in organic lesions 
of the cord has yet to be proved. Judging from its effects, 
v\re should say its direct operation on the tissue was the very 
reverse of nutritive or reparative. If function is, as there 
can be no doubt, the effect of a mode of disintegration, 
agents which directly increase function must produce a dis- 
integrating action. If this be a sound inference — and 
experience leads to the same conclusion — strychnia has but 
a limited therapeutic application in paraplegic affections. 
It is well known that immediate and striking effects can be 
produced by this drug, but these are often followed by 
hopeless bankruptcy of the spinal power. In giving strych- 
nia our object should be to produce no greater change of 
the tissue than shall, by the stimulus of waste, increase the 
power of nutrition, as we exercise an organ to favour its 
healthier growth. This requires not only a diagnosis of the 
conditions producing the paraplegia, but a careful adapta- 
tion of the dose of the medicine, which is often a 'difficult 
point. I have seen one twenty-fourth of a grain given 



CASES OF PARAPLEGIA. 217 

twice a day for only two or three days in a case of chronic 
paraplegia, apparently depending upon softening of the 
cord, set up very decided irritation. So unstable is the 
structure of the nervous tissue in some of these cases, and 
so delicate in proportion must be our interference by reme- 
dial agents. 

Case 19 (Plate II, figs. 2 and 3). — Chronic inflammatory degeneration of 
the posterior columns of the cord throughout their whole length ; the 
disease strictly limited to the posterior columns ; frequent vomiting ; 
general emaciation of the voluntary muscles ; para^^legic weakness 
of lower extremities, characterised hy a want of control over the 
contraction of the muscles ; congenital misplacement of the ascending 
colon, which became twisted on itself ; cxcum sloughing. 

William J — , est. 28, of middle stature, fair hair, emaciated, anxious 
expression, large head, broad and prominent forehead. Though he had 
never been robust he had good health until the beginning of the year 1857. 
He was first seized with vomiting, which came on without any discoverable 
cause, and lasted for several days. As he recovered from the attack, the legs 
became weak. After three months he had a second attack of vomiting, 
followed by an increase of weakness in the legs. He was admitted into 
Guy's Hospital under my care, November nth, 1857. He was then unable 
to stand without support. In a recumbent position he could flex and extend 
the legs with some freedom, but the movements were sudden and vague 
fi-om want of control over the action of the muscles ; the spinal centres, 
when stimulated by the will, seeming to shoot oif their influence at once, 
making the feeble muscles contract to their full extent with a jerk. In 
other words, there was no power to regulate the muscular contraction. The 
movements of the fingers were also wanting in precision. He was awkward 
in handling small objects or in applying the hand to grasp larger ones. 
The muscles were thin and flaccid, corresponding to the general emaciation 
of the body. The muscular irritability was excessive. Weak currents of 
electricity, not sufficient to affect healthy muscles, excited well-marked 
contraction ; whilst a little stronger but yet very moderate dose of electro- 
magnetism produced cramps lasting for several seconds after the stimulus 
was discontinued. The arms were weak, with an obvious want of control 
over the voluntary movements. There was numbness of the feet and hands, 
and a burning formication in the fingers and toes. The sensation of the 
other pai-ts of the body was noi-mal. No involuntary contraction of the 
legs. Sphincters good. Urine acid. The lower ribs depressed, and but 
little moved in inspiration. Headache, vertigo, cerebral confusion, tinnitus. 
Pupils largely dilated, the left the most so, sight dim, occasionally transient 
amaurosis. Sleep disturbed by dreams. Frequent nausea and vomiting, 
with pain from the epigastrium to the spine. Abdomen not distended, soft. 
Skin hot and perspiring. Pulse permanently quick, 126, small and feeble. 
Respiration 32. Spine straight. No tenderness on pressure or percussion. 



218 DISEASES OF THE NERVOUS SYSTEM. 

He could give no account of any accident or injury to the spine, except such 
as might have resulted from a fall, tlat on the back, from the height of a 
few feet, eight years before his symptoms began. His habits had been 
temperate. No syphilitic taint. 

After admission into the hospital he continued to have repeated attacks of 
vomiting, lasting for many days, uninfluenced by any remedies. The 
vomited matters were copious, greenish, and mucous. The bowels con- 
tinued to act freely, but without relief to the sickness. The irritability 
of the stomach was attributed to the state of the cord. The attacks of 
vomiting increased his anxious aspect. The paraplegic symptoms continued 
unchanged. There was, as before noted, headache and vertigo, and some- 
times transient amaurosis. The pupils remained permanently dilated, and 
with the same inequality. The pulse quick (120 to 130) and feeble. On 
only one occasion was the urine noticed to be alkaline when first passed. It 
never contained mucus. There was no band-like sensation around the 
abdomen. He often complained of pain from the epigastrium through to 
the spine. About the middle of February, 1858, he first had a sense of 
bearing down about the rectum, and complained of great distress after an 
action of the bowels- and of startings in the legs. March 8th he had an 
attack of vomiting, apparently such as had often occurred before. This 
continued on the 9th. On the loth he was collapsed and pulseless, with 
cold sweats, and other symptoms of ruptured intestine. There was no 
cerebral oppression. He died on the nth. 

Post-mortem examination. — Body emaciated. Brain health}'. Thoracic 
viscera healthy. Faecal extravasation into peritoneal cavity. Intestines 
adherent by recent lymph. Omentum contracted into a cord-like mass, and 
firmly adherent to the left side over the pubes. Caecum fallen into the 
cavity of the pelvis. From it the ascending colon passed directly to the 
left side towards the spleen, and then curved down again before becoming 
continuous with the descending colon. This displacement of the caecum and 
ascending colon arose from a congenital (?) absence of the mesocolon on the 
right side. The ascending colon, at its commencement, was pai'tially 
twisted upon itself. Both it and the caecum were dark coloured, and 
sloughing to a large extent from mechanical obstruction. The spinal cord 
had its normal api)earance and consistence, except, perhaps, a small portion 
in the dorsal region, which seemed rather softened ; but this was doubtful, 
and was only such as an accidental tension in moving it from the canal 
might have pi'oduced. Sections of the cord made at the time gave no 
further evidence of disease. The membranes were healthy. After harden- 
ing the cord and making fine sections it was seen that the posterior columns 
were atrophied throughout their whole length, and amongst the tissue were 
numerous exudation cells in a state of fatty degeneration (granule cells). 
The posterior roots and the lateral columns were normal (Plate II, figs. 2 
and 3). The disease was limited above by the commencement of the medulla 
oblongata. No degeneration of structure liad occurred in this part. 

Reiiiarhs. — The relation of morbid conditions to each, 
other is often difficult to determine. It was so in this case. 



CASES OF PARAPLEGIA. 219 

The oldest disease was, no doubt, that discovered in the 
abdomen ; the absence of the mesocolon on the right side 
was evidently congenital, and probably the adhesion of the 
great omentum dated also from an early period. It was 
these lesions which brought about the fatal result. The 
steps of the process may be looked at in two ways. It may 
be admitted that a ceecum and colon left to float free were 
in danger of getting into positions unfavorable to the pro- 
pulsion of their contents, and thus of occasioning attacks of 
vomiting, such as ushered in the other symptoms in this 
case, and continued to harass and distress the patient 
throughout his illness. It may also be thought probable 
that attacks of abdominal disturbance might, through inci- 
dent nerves, set up a secondary lesion in the cord. This, 
however, is doubtful, and it is more in accordance with our 
pathological views to refer the early attacks of vomiting to 
the lesion of the cord itself as the primary disturbance, 
especially since the degeneration of the columns extended up 
to the neighbourhood of the medulla oblongata. With this 
view it is not difficult to understand how the congenital 
defect in the colon should be brought into fatal operation 
by irregular peristaltic action so induced. 

The limitation of the disease to the posterior columns was 
remarkable (Plate II, figs. 2 and 3). Though they were 
degenerated throughout their whole length from the lumbar 
portion to the medulla oblongata, neither the posterior roots 
of the nerves nor the adjacent parts of the lateral columns 
were in any way involved in the degeneration. We might, 
from this strict limitation of the lesion, hope to gain some un- 
equivocal evidence as to the physiology of these structures. 

The affection of sensation was limited to numbness and 
formication of the hands and feet. Dr. Brown-Sequard has 
shown, by transverse section of the posterior columns in 
animals, and by instances of disease in the human subject, 
that where the posterior columns are destroyed for a limited 
extent, as by pressure of a tumour, hyperassthesia is pro- 
duced in the parts below the injury; in both extremities if 
the lesion affects both columns, but only on the side of the 
lesion if one column is affected. When, however, the pos- 
terior columns are destroyed throughout their whole length. 



220 DISEASES OF THE NERVOUS SYSTEM. 

instead of liyperEestliesia, there is loss of sensibility to some 
degree. Not that the posterior columns convey, according 
to this observer, sensitive impressions to the brain, but 
because, being in part channels through which the fibres of 
the posterior roots reach the grey matter, if they are de- 
stroyed or degenerated throughout, a certain number of 
sensitive fibres must be destroyed also. So far theory 
coincides with the facts noticed in this case. 

The same physiologist believes that the special function 
of the posterior columns is for the reflex movements. These 
functions ought, therefore, to have been destroyed, or at least 
greatly diminished. Nothing in favour of such a theory was, 
however, noticed, except the general muscular emaciation. 

The sphincters of the rectum and bladder continued to 
perform their office. The muscles remained in a state of 
hyper-excitability to the galvanic stimulus. I do not know 
how far the state of the colon might be referable to a loss 
of the reflex power. 

Neither were the phenomena more in favour of the value 
of the test proposed by Dr. Marshall Hall, for the diagnosis 
of cerebral from spinal paralysis, since, according to that, 
the irritability of the muscles should have been much 
diminished, the disease being in the cord ; but, on the con- 
trary, it was remarkably increased. 

This brings us to the theory of the posterior columns 
proposed by Dr. Todd, that they " propagate the influence 
of that part of the encephalon which combines with the 
nerves of volition to regulate the locomotive powers, and 
serve as commissures in harmonising the actions of the several 
segments of the cord.'' The want of power in this case to 
regulate the action of the muscles was very charactei'istic. 
The legs, when drawn up, as they could be freely, were 
drawn up with a sudden jerk, and extended in the same 
manner. The voluntary movements of the hands were also 
fumbling and vague. 

The limitation of the disease to the posterior columns coin- 
cides with what is generally found. There is evidently a 
tendency in lesions to spread longitudinally in the cord rather 
than transversely through it, — probably from homogeneity 
of structure or from the arrangement of the blood-vessels. 



CASES OF PARAPLEGIA. 221 

Sucli complete and symmetrical isolation of a structure is 
very suggestive of an independent function. 

It is unnecessary to refer particularly to the character of 
the morbid changes in this case. They were evidently of 
that kind which we denominate by the term " chronic inflam- 
mation,'^ — atrophy of the proper tissue, with exudation, 
which corpusculates and then becomes fatty. This change 
was probably induced by the fall on the back eight years 
previously. 

In the ordinary mode of examination the disease of the 
cord in this case must have been overlooked, and it would 
probably have been regarded as one due to cerebral disease, 
though certainly there was no evidence of it post mortem. 
Clinically, there was more to support such a view, namely, 
headache, vertigo, cerebral confusion, tinnitus, dilated pupils 
(one larger than the other), dim vision, occasionally transient 
amaurosis, sleep disturbed by dreams, &c. These symptoms 
— together with power to move the limbs when in a recum- 
bent posture, but inability to stand without support, and 
apparently a great increase of all the symptoms when the 
patient is in a vertical position — led Dr. Baillie to assume 
that the seat of the disease in these cases is in the 
encephalon. In the year 1848 I proposed a classification 
of paraplegia which should i*ecognise the existence of such 
cases ; but a better method of investigating the morbid 
changes in the cord daily lessens the number of instances 
referable to such a division, and makes it doubtful whether 
paraplegia properly so called is ever due to lesions which are 
strictly cerebral in their seat. 

Case 20. — Paralysis of both seventh nerves ; nearly com'plete ^paraplegia 
of lower extremities ; weakness of upper extremities ; onset of sym- 
ptoms acute ; death on the ninth day ; for some months preceding the 
invasion of the paraplegic symptoms pains in the left arm and slight 
wasting of the muscles, supposed to he rheimnatic ; wasting of the 
grey commissure on the left side of the cord in the cervical region ; 
recent inflammatory exudation into the tissue of the medulla oblongata 
and into the grey commissure of the cord. 

Mr. E — , set. 59, began to suffer from pain in the left arm, from the 
shoulder to the elbow, at the end of the year 1856. The pain continued 
some mouths, and left the arm weak and slightly wasted. This was regarded 



222 DISEASES OF THE NERVOUS SYSTEM. 

as a rheumatic affection. There was no anaesthesia ; Mr. E — was in other 
respects in good health until Christmas, 1858. He could give no more 
precise description of the beginning of his indisposition than that he was 
languid. He spoke also of an occasional feeling of coldness between the 
shoulders and down the spine, attended with distressing rigors in the spinal 
muscles. At the beginning of March, 1858, he had bilious vomiting, with 
pain in the right hypochondrium. He was able to continue the active 
duties of his profession as a medical practitioner, and gave a public lecture 
on the evening of the 29th of March, but said that he felt more weak and 
tremulous on that day than usual. He visited his patients on the 30th, and 
appeared in his ordinary health, but in the evening complained of constrict- 
ing pains in both arms, from the shoulders to the insertion of the deltoid 
muscles. On rising from bed on the morning of the 31st he found his legs 
too weak to support him, and fi'om that time his paraplegic symptoms 
rapidly increased. I visited him on the 4th of April. There was then 
entire inability to move the muscles of expression on either side of the face. 
The involuntary action of the orbiculares palpebrarum continued, but the 
eyes could be only pai'tially closed by volition. The features hung motion- 
less. He first noticed the paralysis of the face the day previous, when 
attempting to put up his lips to kiss his wife. The motor and sensitive 
divisions of the fifth nerves were unaffected, except slight ansesthesia of the 
first division on the left side. Motions of the eyes, vision, hearing, taste, 
and deglutition normal. Respiration chiefly abdominal, the movements of 
the lower ribs being defective. Numbness of the fingers of both hands. 
Movements of upper extremities free. He lay supine with the legs 
extended and powerless. Muscles flaccid. No excito-motor movements on 
irritating the soles of the feet ; sensation impaired, and a feeling as of a 
board pressed against them. Tlie sphincters retained their power. Urine 
pale straw-colour, acid. Intellect perfectly clear. Tongue protruded 
straight. Articulation perfect for all words not requiring the use of the 
lips. Labials could not be pronounced. Pulse 72. Eespiration tranquil. 
On closer inquiry as to any premonitory symptoms it was elicited that in 
the summer of 1857, on one occasion in sleep, an evacuation had passed 
from him involuntarily. This was the only evidence of spinal disorder 
except that given above. On the 6th there was a slight return of power 
over the muscles of expression. The paraplegic symptoms, however, were 
unchanged. On the 8th the respiration was more feeble, and chiefly abdo- 
minal. Tongue dry and brown. Dribbling of urine. When roused he 
was quite collected, but left to himself there was wandering delirium. 
Movements of arms very feeble ; slight subsultus. He died in the evening 
very tranquilly, the breathing ceasing so gradually that the last respiration 
could not be told. 

Post-mortein examination. — Rigor mortis well marked, both in upper 
and lower extremities. Large amount of subcutaneous fat over chest and 
abdomen. Muscles of lower extremities well developed. Left arm slightly 
less muscular than right. Large deposit of fat about the base of the heart 
and over the right ventricle ; valves healthy ; aorta extensively atheromatous. 
Lungs healthy. Univereal, old, tough adhesions between the diaphragm and 



CASES OF PAEAPLEGIA. 223 

upper surface of liver. No corresponding adhesion of the pleura above. 
Kidneys large, tunics easily stripped off, surface smooth. Bladder healthy. 
The convolutions of the hemispheres of the bi'ain separated by clear sub- 
arachnoid effusion. No other abnormal change. Corpora striata, thalami 
optici, cerebellum, and pons Varolii healthy. The basilar and vertebral 
arteries opaque and rigid. The trunks of all the cerebral nerves healthy. 
Bones, ligaments, and membranes of the spine healthy. In the cervical and 
dorsal regions the substance of the cord was to the touch somewhat softer 
than natural, but no other unequivocal change was discoverable by the 
unassisted eye, or by the aid of a common lens. On hardening the pons 
Varolii, medulla oblongata, and cord, and preparing sections after a modifica- 
tion of Lockhardt Clarke's method, it was seen that in the anterior part of 
the commissure, throughout the length of the cord, but principally in the 
lumbar and superior cervical regions, and throughout the structure of the 
medulla oblongata, but chiefly at its superior part, there were exudation 
cells scattered interstitially amongst the tissue ; they were also seen, but 
more sparingly, in the lines of areolar tissue which radiate through the 
white substance and amongst the deeper part of that which dips into the 
anterior commissure. There was no want of continuity nor any destruction 
of the nervous tissue. The cells were recent, and had not undergone 
fatty degeneration. The amount of the exudation was so small and its 
distribution such that no lesion was visible, except under the higher powers 
of the microscope. It was then very distinct, and remains so in the sections 
preserved in Canada balsam. In the cervical region on the left side there 
was wasting of the grey commissure and a development of fibrous tissue in 
its place. 

Remarhs. — The supposed rheumatic affection of the left 
arm was referable to the changes in the grey commissure 
in the cervical region. This change was very limited in 
extent, but still very definite when transparent sections of 
the cord were examined. The experiments of Brown- 
Seqiiard — which go to prove that injury to the grey matter 
of the cord on one side alters the sensibility on the opposite 
side of the body — seem opposed to the facts in this case. It 
is probable, however, that the painfnl affection of the left 
arm was due to a lesion of the motor nerves — the chronic 
changes in the muscles subjecting the textures to unnatural 
tension. 

The paralysis of both seventh nerves was a striking 
incident in the case. It was referable to the central changes 
which extended through the tissue of the medulla oblongata. 
The nerve-trunks and surrounding parts were healthy. The 
exudation estimated in mass was very trifling, not suSicient, 



224 DISEASES OF THE NERVOUS SYSTEM. 

indeed, to give unequivocal evidence of its presence but for 
our improved methods of research. It is not, however, 
to be forgotten that its seat was in the most important part 
of the nervous centres, where nature has afforded no sur- 
plusage. 

The defective speech led those about the patient to sup- 
pose the symptoms were due to disease of the brain. It, 
however, needed but little investigation to show that this 
defect was entirely due to paralysis of the lips, and was 
limited to the pronunciation of labials, other parts of speech 
being pronounced distinctly. 

The intellect was undisturbed. The patient gave a very 
clear account of himself. The tongue was moved freely. 
Digestion unimpaired, and the breathing natural. 

The diagnosis was of softening of the cord, but strictly 
speaking- this was not the lesion. It was an inflammatory 
exudation into the more vascular parts of the cord and 
medulla oblongata. To what condition of the circulating 
fluids or of the blood-vessels this was attributable is con- 
jectural. The patient was a beer and porter drinker, his 
subcutaneous tissues were loaded with fat, his age fifty-nine, 
— conditions which are associated with and favour a gouty 
state no doubt much oftener than the occurrence of distinct 
gout would seem to indicate, for a patient may be gouty who 
has never had gout, as one may be poisoned by marsh 
miasm who has never had ague. There was no history of 
injury or of exposure to cold. The effusion under the cere- 
bral arachnoid was probably the result of that capillary para- 
lysis (congestion) which comes on in death from disease of 
the nervous centres. 

Case 2 1 . — Sudden paralysis of right leg ; partial recovery after five 
months' acute paraplegia; erysipelas and consecutive pneumonia 
from the application of heat to the legs ; irritative fever, and death in 
two weeks ; recent softening of the cord in the dorsal region ; old 
degeneration of the right lateral column, with fatty incrustation of 
the capillaries. 

Ed. M — , set. 34, a man o£ dissolute habits, but originally of a strong and 
well-developed constitution. At the end of November, 1853, on rising from 
his bed felt himself suddenly powerless in the right leg. He had at the 
same time pain in the lumbar region, extending to the hypochondria. 



CASES OF PAEAPLEGU. 



225- 



There was no anaesthesia. He asserted that he had felt nothing wrong with 
himself previously ; and, so far as he knows, there had been no premonitory 
symptoms of the paralysis. For more than a month the leg remained 
completely paralysed, " there was not the slightest power of motion in it." 
Pain in the course of the sciatic nerve. Urine drawn off by the catheter, 
ammoniacal. Frequent priapism with spermatic discharges (as proved by 
microscopic examination), but he was not himself aware of any excitement of 
the genital organs when questioned about it. He was treated by 'Mv. 
William Hills with laxatives, the preparations of iron and strychnia, and by 
galvanism. Slowly the pain left him, and he recovered some power over 
the leg so as to be able to stand upon it, and to walk with the aid of a stick, 
but he could not flex the muscles of the hip-joint. With this improvement 
he relapsed into his former habits, and after a week rather suddenly became 
paraplegic. He was admitted into the hospital April 29th, 1S54. The 
right leg was then wasted and completely paralysed. Slight power remained 
in the left leg, and there was frequent involuntary jactitation of it. It was 
swollen from erysipelatous inflammation which had extended from a bulla 
caused by the application of a hot bottle. Irritative fever followed, and 
death at the end of a fortnight from the time of the relapse. 





1^ 1 C« -a-j n^SPfU-X-^ 







Sketch of capillaries inerusted with oil-globules, Case 21. 



Post-mortem examination. — On the left leg superficial excoriations and 
the remains of blebs. Subcutaneous cellular tissue containing collections of 
pus. Saphena vein not implicated. Bones, ligaments, and membranes of 
spinal cord healthy. Large quantity of transparent cerebro-spinal fluid. 
In the upper dorsal region the substance of the cord was softened to the 
extent of an inch ; exudation-cells scattered through the tissue. In the 

15 



226 DISEASES OF THE NERVOUS SYSTEM. 

right lateral column, near the same part, the tissue was atrophied and the 
capillaries incrusted with oil-globules (see Fig., p. 225). 

The fatty matter could be removed by ether, leaving the walls of the 
vessels apparently normal. This change was strictly limited to the right 
side of the cord. Eecent lymph on lower lobe of right lung. Pneumonic 
consolidation of the bases and posterior parts of both lungs. Liver pale, 
weight 4 lbs. 3 ozs. Kidneys congested, weight 12 oz. Mucous membrane 
of bladder thickened, congested, and greenish. 



Remarks. — The cliief pathological intei'estof this case lies 
in the suddenness of the paralysis in the first instance, and its 
limitation to the right leg. The cause of this was plainly 
made out on examination of the cord. The incrustation of 
the capillaries with oil-globules appeared to be nothing more 
than a mechanical result, and not due to a degeneration of 
the coats of the vessels. In pathological changes of the 
nervous substance we may distinguish these two conditions. 
In the one the changes in the capillaries are probably ante- 
cedent to the lesion of the textures, and in the other con- 
secutive to it. 

It is a matter of speculation what set up the softening. 
Dissolute habits induce many conditions predisposing to such 
a change ; and amongst them, perhaps, none more efficient 
than the contamination of the syphilitic virus. In softening 
of the brain there can be no doubt of this connection, and 
that, too, apart from any noticeable cachexia. 

The seat of the softening corresponded with that so fre- 
quently found in other cases. The dorsal region, from its 
position and organisation, is exposed to lesion, and the cord 
has, perhaps, at this part, less resisting power than at other 
parts which are more highly organised. 

Case 22. — Paraplegia supervenincj two days after a violent exertion in 
lifting a heavy weight; softening of the cord opposite the fifth and 
sixth dorsal vertebne ; no injury of the membranes, ligaments, or 
bones of the spine ; death after six weeks. 

Richard A — , fet. 25, of a rather delicate constitution, was at his usual 
occupation as a labourer in the Commercial Docks on Saturday, November 
22nd, 1856, when, after lifting some deals, he felt a sudden pain in the 
back. He walked to his home, the distance of a mile and a half, and the 
following day was apparently quite well. The next morning (Monday), on 
waking, the legs were paralysed. When admitted into the hospital. 



CASES OF PARAPLEC4IA. 227 

November 26th, there was complete paraplegia, a bedsore had already begun 
to form over the sacrum, and ammoniacal urine dribbled from the bladder. 
He died exhausted, January 2nd, 1857. 

Post-mortem examination. — Body emaciated ; large bedsore exposing 
the whole length of the sacrum. The bones and ligaments of the spine in 
the other regions were carefiilly examined, but no trace of injury was 
discovered. Opposite the fifth and sixth dorsal vertebrae the cord was 
softened through all the columns into a thick, greenish, muco-puriform 
fluid, with a tinge of brown. Examined by the microscope, it was seen to 
consist of disintegrated nerve-tissue, with a few irregular collections of 
granules. The cord ivas not enlarged at the softened part, nor was there 
any trace of inflammatory exudation in it or upon the membranes 
covering it, though to the unassisted eye it had the appearance of an 
irregular undefined abscess. The lumbar and cervical portions of the cord 
had the normal appearance and firmness. A large portion of the lower lobe 
of the right lung and half the upper lobe of the left were hepatised. Heart 
normal. Liver large and fatty. Commencing suppuration in the cortical 
substance of the kidneys. Mucous membrane of the pelves greenish, witli 
patches of adherent fibrinous exudation. This condition of the mucous 
membrane was continued through the uretere into the bladder. The bladder 
contained a quantity of muco-purulent fluid. 

Remarhs. — This case shows that the substance of the cord 
may receive an injury through violent muscular exertion, 
whilst the surrounding textures escape. Why this should 
rather occur in the dorsal region is obvious, since the curve 
of the column is most marked and most variable, and the 
body of the cord is thinnest, at this part. It is a matter 
also of common clinical experience that the cord is very 
prone to softening in the dorsal region, from which we may, 
perhaps, infer that, in addition to its being here more subject 
to injury, it has a more feeble organisation than the cervical 
and lumbar enlargements. The change in the cord was 
seen by the microscope to be due to mere disintegration. 
There was no evidence of any plastic exudation. The 
greenish and brownish tints of the softened part were pro- 
bably due to blood-colouring matter. We may infer, from 
the quality of the local changes, which appear to have been 
quite passive, and from this slight coloration, that the 
immediate effect of the injury was upon the capillary 
circulation, leading to effusion of blood and consequent 
atrophy. 



228 DISEASES OF THE NERVOUS SYSTEM. 

Case 23. — Concussion of the cord in the cervical region from direct 
violence ; ecchymosis into posterior horn of grey matter on left side, 
also into anterior horn on right side and into the posterior columns ; 
loss of sensation immediately after the accident, followed by hijper- 
sesthesia ; paralysis of legs, left arm, and sphincters ; death thirty- 
four hours from the accident. 

(Repoi-ted by Mr. Bankaet.) 

Joseph K — , a3t. 33, a coal-porter, strong and healthy, was carrying a sack 
of coals on his back, down some cellar stairs, when his foot slipped forwards 
from under him and he fell, the sack of coals falling upon him. On his 
admission, immediately after the accident, 3 p.m., June 22nd, 1858, there 
was loss of motion of both legs and of the left arm. The sphincters were 
paralysed. There was entire loss of sensation in the left arm as high as the 
deltoid. The right arm he could move, and had perfect sensation in it. On 
examining the state of sensation in the lower extremities, it was found that 
he could feel about the feet and on the outer side of thighs, but not on the 
anterior and inner surface. During the time marks were being made on 
the skin to indicate the state of the sensation at different parts, it was 
found to vary, returning to spots where it had just previously been absent. 
Apparently the most distant parts recovered first. Slight priapism. 
Breathing diaphragmatic. After a few hours sensation returned in every 
part. As the skin became warm he complained of pain when lightly touched. 
For instance, when the finger-nail was passed but lightly along the skin he 
would exclaim, "Don't prick me ! don't hurt me !" The day following, the 
sensibility of the surface appeared to be excessive, judging by his exclama- 
tions when the skin was touched or pinched. This was especially noticed in 
tlie right arm. Priapism, whicli existed when he was admitted, passed off 
after two hours, but returned the day following. He continued to have 
power to move the right arm. He died thirty-four hours from the 
accident. 

Fost-mortem examination. — The spine only was examined. There was 
no external trace of the injury ; no displacement of the vertebras discover- 
able by external examination. The membranes of the cord were healthy. 
Opposite the fourth and fifth cervical vertebraj the substance of the cord 
was contused. On section there was found ecchymosis of the posterior horn 
of grey matter on the left side, and of the adjacent part of the lateral and 
posterior columns. There were also other limited spots of ecchymosis on 
the right side, one in the right posterior column, and one in the anterior 
cornua of the grey substance. The grey matter generally was hyperaemic 
(from venous congestion?), but there was no other lesion of it except at 
the two spots named ; no lesion of the anterior columns. The commissure 
was uninjured. On examining the spinal canal after the removal of the 
cord, nothing abnormal was discoverable in the bodies of the vertebrai 
opposite the lesion of the cord ; but on dissecting off the posterior ligament 
it was seen that the body of the fourth was separated from that of the fifth, 
and that the left articular process of the fourth had been chipped off by 
the violent pressure of the lower one against it. 



CASES OF PARAPLEGIA. 229 

Remarks. — There are several points wortliy of note in this 
case ; the character of the injury received by the cord, 
namely, limited capillary ecchymosis ; the absence of any 
external sign of the injury ; the mode by which the cord 
was injured, namely, by concussion, and not by pressure of 
surrounding parts upon it, as shown by the ecchymosis 
being in the substance of the cord, whilst its peripheral 
parts and membranes had escaped ; the limitation of the 
injury, producing paralysis of the left arm, whilst the right 
retained the power of motion ; the immediate effects of the 
concussion on the cord, producing anaesthesia for a few 
hours ; the return on sensibility first in the parts most 
distant from the injury, and the development of hyper- 
aesthesia. This latter symptom was in accordance with the 
experiments of Sequard, who has shown that injm-y of the 
posterior cornua of the grey matter is followed by hyper- 
Eesthesia of parts below. Cases of injury, as before re- 
marked, have as much interest to the physician as to the 
surgeon, since they often come under the care of the 
physician for the treatment of the permanent effects ; when 
it is necessary there should be a correct estimate of the 
character of the primary lesion. 



Case 24. — Concussion of the cord hy a fall; recovery of power after two 
hours; subsequent effusion of blood outside the tlieca vertebralis in 
the nech ; j^araplegia of upper and lower extremities ; paralysis of 
intercostals ; intense heat of skin ; death in fifty -five hours. 

(Reported by Mr. Vendue.) 

Robert L — •, set. 40, fell backwards from a moderate height, a heavy plank 
falling at the same time upon him. He was at once brought to the hospital 
(4 p.m., July 7th, 1858). He was collapsed, but sensible. There was entire 
paralysis of the left leg, partial of the right, and also partial paralysis of the 
arms, but he was still able to flex the fingers. After two hours he had so 
far recovered from the immediate effects of the injury that he could draw 
up his legs and grasp the hand ; the circulation was improved surface 
wanner. No injury of spine discoverable. At 10 p.m. he said he felt com- 
fortable. He passed a restless night, and the following morning, at 8 a.m., 
was entirely paraplegic both in the upper and lower extremities. Loss of 
sensation in the paralysed parts. Priapism. Ribs scarcely moved in 
inspiration. Temperature of surface increased. Abdomen tense and tym- 
panitic. During the day the skin became intensely hot, but the actual 



230 DISEASES OF THE NERVOUS SYSTEM. 

temperature was not noted. The breathing was wholly diaphragmatic. 
Deglutition difficult. He died fifty-five hours from the accident. 

Post-mortem examination by Mr. Bryant. — No external evidence of 
injury to the spine. On dividing the soft parts there was found a separa- 
tion between the fourth and fifth cervical spinous processes, and dislocation 
of the articular processes. The interspinous and capsular ligaments were 
torn through. Extravasation of blood outside the theca vertebralis on its 
anterior aspect. The effused blood compressed the cord, which was other- 
wise uninjured. After careful examination there were not found any signs 
of bruising of its tissue. The extravasation apparently arose from injury 
to the lower part of the body of the fourth vertebra, which had been 
fractured, and the intervertebral substance torn. The calibre of the canal 
was slightly encroached upon by displacement of the fourth vertebra, but 
not so as to press on the cord. The extravasation, though most abundaiit 
opposite the injury, extended downwards to some distance. The membranes 
of the cord were uninjured. 

Case 25. — Cervical •paraplegia following an injury ; progressive muscular 
atrophy of the upper extremities, most marhed on the side of the 
principal lesion in the cord; aneesthesia, with severe neuralgic pains 
on the opposite side ; paroxysms of hiccup for several inonths ; thich- 
ening and adhesions of the membranes of the cord ; degeneration of 
the posterior columns ; dilatation of the ventricle of the cord ; opacity 
and fatty degeneration of the arachnoid of the brain _,• ependyma of 
ventricles granular. 

John G — , set. 49, a coal waggoner, was forced backwards from his seat 
by striking his head against a beam whilst driving under an archway. 
Several ribs were fractured on the left side. Some months after this 
accident he began to suffer pain from the occiput down over the shoulders, 
and in about a year the muscles of the upper extremities began to waste. 
After two years incontinence of urine gradually came on. He was admitted 
into Guy's Hospital February nth, 1857, three years from the time of 
the accident. He then presented a remarkable example of muscular atrophy 
without actual paralysis. The upper extremities were principally affected. 
The extensors of the right hand, the muscles of the thumb, and the inter- 
ossei were extremely wasted. The wrist dropped. The muscles of the 
shoulder and arm, including the pectoralis major and minor, much wasted, 
but in a marked degree less so than those of the forearm and hand. Very 
slight diminution of sensation. He could still lift the arm over the head. 
The left arm was similarly but less affected than the right, so far as regards 
muscular atrophy, but there was numbness through the whole arm down to 
the fingers, and he suffered severely from neuralgic pains in it, which greatly 
depressed him, and which he described as a compound of smarting and 
numbness. The trapezii, serrati postici superiores, rhomboidei, and all the 
long muscles of tlie neck and back, were remarkably atrophied. The spinous 
processes were very prominent. No deformity nor tenderness on pressure 
at any point. The intercostals were so weak that the only respiratory 



CASES or PARAPLEGIA. 231 

movement was through the diaphragm. The supra-spinati were atrophied, 
but not to the same extent as the infra-spinati and levatores anguli scapula}. 
The legs were wasted and weak, but he was able to walk. Sphincters weak. 
Dribbling of urine. Constipation. The thorax looked narrow and ill 
developed from the wasting of the pectorals, the intercostals, and erectores 
spinse muscles. The muscles at the back of the neck and the sterno- 
mastoids were so weak that the head could not be supported erect. Sight 
dim, drooping of left eyelid. Frequent hiccup for many months. After 
his admission his principal complaint was of pain in the left arm from the 
clavicle to the fingers. He described it as a severe smarting with a sense of 
numbness. His distress from this cause was very great. At the early part 
of March febrile symptoms set in. Tongue became dry and brown. Fre- 
quent hiccup and vomiting. Pain in left arm severe. Dyspnoja. Died 
March 25th, 1S57. 

Post-viortem examination. — The arachnoid of the brain opalescent, with 
spots of white mottling of the more opaque parts from fatty degeneration. 
Subarachnoid fluid in excess. Ependyma of lateral and fourth ventricles 
granular, in the latter extremely so. The dura mater on the posterior 
surface of the cord much thickened. The two layers of arachnoid adhe- 
rent in patches along this surface, and much thickened by effusion of 
lymph of old date. Sections of the cord examined with the naked eye gave 
no distinct evidence of disease. There was a slight yellowishness of the 
posterior columns, and increased vascularity and thickening of the pia mater 
covering them. In these columns, especially in the right one, abundance of 
granule-cells were discovered by the microscope. The exudation was 
greatest in the middle and lower third of the cervical enlargement. The 
grey matter was hypersemic. No exudation into its tissue, nor into the 
anterior columns. The ventricle of the cord enlarged and distended with 
delicate granular nuclei. The affection of the cord appeared to be secondary 
to chronic inflammation of the membranes, and to chronic changes in the 
ependyma of the ventricle in common with the ependyma of the fourth and 
lateral ventricles of the brain. Hypostatic engorgement of both lungs, 
several lobules consolidated from recent pneumonia, some greyish. Other 
organs healthy. 

Case 26. — Progressive atrophy of the muscles of the trunk and upper 
extremities after a blow on the neck with the fist. 

Daniel C — , set. 15, received a blow with the fist between the shoulders 
from a boy at play. After a week the head drooped, and gradually from 
that time the muscles of the upper extremities wasted, the arms dropped and 
hung useless, the intercostals lost their power, and the breathing was dia- 
phragmatic ; the lower two thirds of the trapezii and the erector spinas 
muscles also wasted in the same way. This sketch was made fourteen 
months from the injury to exhibit the wasted condition of the muscles and 
the position of the head and trunk ; the head fallen forwards and the 
tmnk thrown backwai'ds to balance it, in the absence of muscular power. 

The flattening of the ribs from the paralysis of the intercostals was such 



232 



DISEASES OF THE NEBYOUS SYSTEM. 



^'^ 



that the heart beat to the right of the 
left nipple and between the third and 
fourth ribs. 

The patient was able to walk about 
when the sketch was taken. His gait 
was vacillating, but apparently more 
from want of muscular power to fix the 
trunk on the pelvis than from defec- 
tive power in the legs. He could not 
sit on a seat without a support to the 
back. Sphincters good. On testing 
the electro-contractility of the wasted 
muscles by galvanism they were found 
to contract in proportion to their mass ; 
those muscles of the upper arm which 
were the less wasted contracted well ; 
those of the forearm and hand which were 
the more wasted contracted less but still 
distinctly. The progress of the disease 
was unattended with any pain. The 
wasted muscles not tender. No flicker- 
ing contractions of their fibres. 



:> 



f?5:% 



Sketch showing wasting of muscles 
after a blow on the neck. 



Remarks. — This case is re- 
corded as a good illustration of 
progressive muscular atrophy 
after concussion of the cord. 
It is to be observed that there 
was no more paralysis than was 
due to atrophy of the muscles, 
and that the electro-conti-ac- 
tility of the muscles was in pro- 
portion to tlieir bulk. These 
facts are of importance, since 
it has been erroneously pro- 
posed to determine by the test 
of galvanism the diagnosis be- 
tween progressive muscular 
atrophy from morbid changes 
primarily in the muscles, and 
that muscular wasting which 
is consecutive to disease of the 
cord. It is said that, in the 
latter case, the muscles early 



CASES OF PARAPLEGIA. 233 

lose their electro-contractility, a statement at variance with 
extended clinical observation, and further illustrated in 
Case 19. No doubt, as the lesion of the cord advances in 
this case (which is still under treatment), the lower extre- 
mities will undergo the same changes as the upper, A pre- 
cisely similar instance (Case 15, with post-mortem examina- 
tion) was recorded in the 'Reports' for 1857. 

Case 27. — Ac^lte rheumatic (?) affection of the larger joints ; parajplegia 
of loicer extremities ; slough over sacrum; recovery. 

Anne E — , set. 39, was admitted into Guy's Hospital, Marcli 31st, 1857, 
under the care of my colleagues Dr. Hughes and Dr. Wilks (to whom I am 
indebted for placing the case at my disposal). Both hands were swollen, 
stiff, and painful, with an erythematous blush over the back of the right 
and on the second joint of the thumb of the left. The legs were so far 
paralysed that she could only very slowly and feebly move them. The 
muscles were greatly wasted and flabby, but had not lost their excito- 
contractility by galvanism. Sphinciters weak. No swelling of the knees or 
ankles at this time. Sensation nearly normal, but at times both legs felt 
numb, and were drawn up involuntarily. Urine acid, high-coloured, and 
scanty. Tongue covered with a cream-like fur ; skin hot, perspiration 
profuse, with acid smell. Pulse 120 ; systolic murmur over ventricle. On 
examining the spine the lower third of the sacrum was found to be bent 
forward, the result of a fall eleven years before ; and near the sacral notch, 
on the right side, was the cicatrix of a wound which formed at that time. 
Except this, there was nothing abnormal, nor any pain or tenderness on 
pressure. The history she gave of her case was, that being a widow, she 
was necessitated to work laboriously at a mangle. She had for two years, 
when much exerting herself, felt pain in the back between the shoulders, 
and a sense of constriction and coldness round the chest. Ten days before 
coming into the hospital she was seized with pain in the left leg, and had 
spasmodic contraction of the muscles, with an increase of the pain, and 
constriction round the chest. She had still power to extend the leg, but 
could not walk. The day following, the hands, knees, and ankles, were 
swollen and painful. With these symptoms there was febrile heat and 
diarrhoea. The sphincter ani was so weak that the faeces ran from her 
involuntarily. On the third day a slough formed over the sacrum. No 
important change occurred in her symptoms after her admission. There 
was great muscular emaciation generally. Involuntary twitchings of the 
muscles of the arms and legs. Aching, gnawing sensations in both calves. 
Touching the feet gave rise to formication, and very lively excito-motor 
movements. For ten days the hands remained red, painful, stiff, and 
swollen. She complained much of the heat and profuse perspirations, 
which returned several times in the twenty-four hours. On the 8th of 
April the urine was ammoniacal, and contained mucus. The hands were 
still swollen and erythematous; face flushed; pulse 100, full, as in rheu- 



234 DISEASES OF THE NERVOUS SYSTEM. 

matism ; acid smell of perspiration ; respiration 28 ; movements thoracie 
and abdominal ; abdomen soft ; pupils large ; nights sleepless. Ordered a 
grain of opium every six hours, with six ounces of wine daily, and a chop. 
On April 13th the good effects of the opium and support were very appa- 
rent. The patient had passed good nights, and was tranquil in the day. 
Perspiration lessened. Urine retained in the bladder for thirty-six hours 
was at length passed voluntarily ; it was acid, and without mucus. Tongue 
pale and moist. The slough on the back had deepened. The pupil still 
continued large. Occasional contraction of the muscles of the legs. No 
permanent rigidity. Hands remained swollen and stiff, but less red. She 
was unable to move the shoulders freely. On April 22nd the hands had 
recovered their normal appearance, and had lost their stiffness. The legs 
could be moved more freely. The sense of constriction round the chest was 
gone ; pulse 96 ; skin cool and dry ; appetite good ; urine normal, but she 
could not empty the bladder oftener than once in twenty-f our hours. From 
this date she slowly recovered. The opium was continued throughout her 
convalescence. At the beginning of June the muscles of the lower extremi- 
ties were galvanized regularly. By the end of the month she was able to. 
stand without help. Her improvement was uninterrupted, and in Sep- 
tember she left the hospital quite well. 

Remarks. — It is a matter of great clinical interest that 
lesions of the cord are occasionally attended with an affection 
of the joints not to be readily distinguished from that which 
occurs in acute rheumatism. When this happens there may 
be difficulty in determining the pathology of a case. It may, 
indeed, be impossible to say whether the symptoms at a 
certain stage are due to disease of the cord, or to a rheu- 
matic state of the blood. In such instances we have a proof 
of the near relations of humoralism and solidism ; for oue 
observer may maintain that the local lesions have a common 
origin in the altered state of the blood, whilst another may 
with equal confidence assert their dependence ujDon a 
primary disturbance of the nervous centres. The case here 
recorded is an example of these difficulties. Fatigue from 
mechanical labour, acting especially on the lumbar and 
dorsal portions of the spine in a delicate and anxious subject, 
appears to have injured the nutrition of the cord. For two 
years, when much exerting herself, the patient felt pain 
between the shoulders, and a sense of constriction and cold- 
ness round the chest. Paraplegia then suddenly came on, 
followed by redness, pain, and swelling of the larger joints, 
as in rheumatism. Together with these symptoms there 



CASES OF PARAPLEGIA. 235 

were others indicating a rheumatic condition — white, furred 
tongue ; flushed face ; hot skin ; profuse perspirations having 
an acid smell ; systolic murmur over left ventricle, &c. 
Was there here a rheumatic state of the blood induced by 
the spinal lesion, or was the nervous derangement the result 
of a rheumatic state ? Notwithstanding the labours of mor- 
bid anatomists and chemical pathologists, we are not at 
present in possession of any certain knowledge of what con- 
stitutes the rheumatic condition. My colleague Dr. Addison, 
from his clinical experience, has long drawn attention to the 
close connection between spinal lesions and true rheumatism, 
but has never developed the idea beyond expressing a sus- 
picion of their relation. 

At the time this case was under care the treatment was 
a subject of much observation. The result was very satis- 
factory. Whatever might have been the state of the cord, 
it was clearly induced by fatigue, and was soon followed by 
sloughing of the integuments. It would not, therefore, admit 
of depletory measures, but, on the contrary, required a nu- 
tritious diet and wine. Opium was prescribed apparently 
with great advantage ; it allayed nervous irritability, and gave 
the patient sleep. 

The following case is also illustrative of the relation 
between spinal injury and rheumatic symptoms. The same 
plan of treatment as above was equally successful. The 
therapeutical view of this subject is certainly not without the 
greatest interest. No doubt the texture of the cord has but 
feeble reparative powers, notwithstanding it has been shown 
by experimenters on animals that occasionally, after a 
transverse section, the parts unite, and the functions are re- 
established. 



Case 28. — Concussion of the spine; partial paraplegia ; redness and 
swelling of the wrists and ankles as in acute rheumatism ; recovery. 

W. T — , set. 38, on the 22nd .January, 1855, inadvertently stepped back- 
wards into a hole, a few feet deep, and received a concussion of the spine. 
After a few days he became partially paraplegic, with weak sphincters ; and 
at the same time there came on a diffused redness and swelling of the ankles 
and wrists. The swelling was not from effusion into the joints, but from 
oedema of the surrounding tissues. The joints were very painful. The 
redness and swelling were variable in degi-ee. When most marked they 



236 DISEASES OF THE NERVOUS SYSTEM. 

presented the usual appearances of rheumatism, or rather of gout, for the 
erythema was brighter, and the cedema more distinct than in rheumatism. 
The hands were equally affected with the ankles, though there was no 
obvious want of muscular power, nor any affection of sensation in the up2:)er 
extremities. Tongue clean. Pulse 120. No acid perspirations. Urine 
high-coloured, free from deposits ; of normal quantity. The nerves of the 
surface generally were hyperissthetic to a slight touch, but deep pressure 
gave less inconvenience. The treatment consisted of good nourishment, 
wine and brandy freely administered, and opium to allay pain and overcome 
sleeplessness. The pulse gradually acquired more power, and sank to 80. 
The affection of the joints continued in varying degree through March, 
April, May, and June. From the beginning of April there was an improve- 
ment in the power over the legs. The same treatment was continued 
throughout without the use of mercurials, local depletion, or counter- 
irritation. In June the patient was able to walk without assistance. During 
sleep, the hands and feet, wrists and ankles, often became erythematous and 
swollen. There was occasional formication in the lower extremities. Sleep- 
lessness, from the beginning of the case and throughout, was a troublesome 
symptom. In July the patient was able to leave the hospital, and to 
resume to some extent his duties as a medical practitioner. He was under 
the care of my colleague Mr. Cock. 

Case 29 (Plate III, figs, a, b, c). — Aniesthesia of left arm without any 
other symjitom. After three years, gradual loss of muscular power 
in the arm, with wasting of the tnuscles ; subsequently a similar 
affection of the right ann, but in a less degree. Death from general 
paraplegia at the end of five years from a fall, by which the anterior 
columns of the cord were ruptured in the lumbar region. Thickening 
and adhesions of the meninges, especially in the cervical region of 
the cord ; atrophy of the posterior coluinns, of the posterior roots of 
the nerves, and of the grey substance, tvith a development of fibrous 
tissue. 

Mary S — , set. 38, a nurse in Guy's Hospital, complained in 1853 of 
anaesthesia of the left arm, which had come on gradually for nearly a year. 
There appeared to be entire loss of feeling below the elbow, but, on testing 
the sensibility upwards to the shoulder and over the scapula, she gave 
vague and often contradictory answers, at one time affirming, and at another 
denying, that she perceived impressions made upon the same points of the 
skin. This discrepancy was perplexing, and led at the time to the belief 
that her ailment was either feigned or hysterical. The sensibility at the 
upper part of tlie thorax, in the axilla, and at the inner part of the arm, was 
perfect. The muscles were well nourished, the movements powerful and 
well directed ; but the antesthesia was so complete that she was unable to 
hold anytliing in the hand if her eyes were off it. She often complained of 
gnawing i)iiins extending down the back, across the shoulders, and into the 
left shoulder-joint ; these pains were increased by the changes of weather. 
Her symptoms continued unaltered for two years. The following note was 



CASES OF PAEAPLEGTA. 237 

made of her case in December, 1855 : — " Complete anaesthesia limited to the 
left arm, no wasting of the muscles, no affection of the leg on the same side, 
general health in all respects good. Electro-contractility of the muscles of 
the affected arm good. Electro-sensibility greatly diminished. During the 
next two years there was gradual loss of power, principally in the left 
shoulder, but also generally throughout the arm, with marked wasting of 
the muscles. The right arm became at the same time similarly affected, 
but in a much less degree. She walked quickly, but with a shuffling gait. 
The left leg was dragged. She was unable to lift the arms over her head, 
or to extend them horizontally, but when they hung down she could grasp 
with tolerable firmness and carry heavy weights. She continued to make 
frequent complaint of pain in the arms and often down the back, and of a 
feeling of weight at the epigastrium. Her manner was often excited,her nights 
restless, and she was subject to attacks of tremulousness and chilliness like 
ague, with a sense of general numbness. About the middle of December, 
1857, she accidentally fell forwards upon the stone steps of the hospital, 
from stepping upon her dress whilst assisting a patient into a cab. Her 
left temple was cut, and she was rendered insensible by the fall. On 
recovering consciousness, a short time afterwards, the legs were found to be 
quite paralysed, and there was almost entire loss of sensation. The weak- 
ness of the arms was greatly increased. There was entire loss of sensation 
below the elbows, and but feeble traces of sensibility above. The muscles 
were also much wasted. After the accident, the urine became ammoniacal 
and contained pus. The skin over the sacrum rapidly sloughed, and she 
died exhausted at the end of a month. 

Post-mortem examination. — General wasting of the muscular system. 
Lateral ventricles of brain dilated and containing clear fluid. The septum 
lucidum perforated in many places from atrophy. No disease of the bones 
or ligaments of the spine. The dura mater of the cord was much thickened, 
apparently by chronic inflammation. This thickening was most marked at 
the lower part of the cervical enlargement, and along its posterior surface 
(Plate III, B, c). In the dorsal region there were plates of true bone, 
formed by ossific degeneration of the inner layers of the thickened dura 
mater. One of these plates opposite the third dorsal vertebra was half an 
inch in length, a third of an inch in width, and a line and a half thick. As 
these plates were developed by degeneration of the layers of the fibrous 
membrane, they merely enveloped the cord without producing any pressure 
upon it. The arachnoid was thickened and opaque, and the two surfaces 
adherent. In the visceral layer in the lumbar region several cartilaginous 
(fibrous) plates. These changes were most marked in the neck, but were 
continuous down to the cauda equina. The texture of the cord itself had 
undergone important changes, as shown in Plate III. About half an inch 
below the medulla oblongata, on the left side, there was a cyst occupying 
the position of the grey matter. Its walls consisted of fibrous tissue and 
compressed nerve-tissue. There was a similar but smaller cyst on the 
ri^ht side, at a lower level. No more than a trace of it comes into view in 
the section drawn (fig. a). The cysts contained colourless limpid fluid. At 
the cervical enlargement, as seen at a, b, the posterior columns and the 



238 DISEASES OE THE XEKTOrS SYSTEM. 

grev matter were estremelv degenerated. They consisted of some remains 
of the columns, embedded in a stroma of fibrous tissue. The posterior roots 
of the spinal nerves were included in the degeneration, and the sheaths 
were thickened in common with the surrounding membranes. The section 
at B shows this. The lower section at c did not happen to include the 
nerve-roots, though the same conditions obtained. The anterior columns 
and portions of the antero-lateral columns were normal, except in the dorsal 
region, where the anterior columns were ruptured transvei-sely across, appa- 
rently at a recent date, and probably by the fall which brought on the fatal 
symptoms. Viscera of chest healthy. Liver healthy. Acute suppuration 
of both kidneys ; the secreting tissue full of small purulent de^wsits. 
Mucous membrane of the pelves dark-coloured and covered with fibrinous 
exudation. Bladder acutely inflamed ; the mucous membrane had sloughed 
away, scarcely a shred was left on the muscular coat. 

RemarJis. — The error committed in the early diagnosis of 
this case was one likely to happen, especially as the patient 
was a woman. She complained of numbness of the arm. 
There was nothing visibly wrong with it on the closest exa- 
mination. The muscles were well developed, the move- 
ments were normal^ and so were the circulation and tempe- 
rature. Besides her own account of the numbness there was 
nothing to indicate disease of the cord or nerves. Her state- 
ment, that if she took her eyes off anything held in the hand 
forthwith she dropped it, was the only circumstance which 
appeared to have any value as a symptom^ and even this 
was lessened by testing the sensibility. When the patient's 
head was turned away, and she was unable to see what was 
done, the point of a needle was passed sharply over different 
parts of the arm. Below the elbow there was a uniform tes- 
timony to the absence of all feeling, but upwards there was 
every kind of contradiction. "When she denied feeling at a 
part a minus sign was put on it with a pen ; when she af- 
firmed it a j)lus sign was marked. After mapping out the 
skin with plus and minus signs the parts were again tested, 
and with contradictory results ; the plus signs fell over the 
minus spots, and the minus signs over the spots before 
marked with plus signs — and so on, in the most uncertain way, 
as often as the trial was repeated. This led to a hasty and 
false conclusion that the patient was feigning, or that her 
malady was the vagary of an hysterical state. Further clin- 
ical observation in otlier cases, and the examination of the 



CASES OF PAEAPLEGIA. 239 

cord in this, have elucidated what was at its early stage so 
bewildering. Wlien the sensibility of a part is obscure or 
doubtful, the testimony of the individual as to impressions 
made upon it may be also doubtful. The same occurs to us 
with our healthy sensibilities when, conversely, weak im- 
pressions are made upon us. When we look at an object 
scarcely visible, at one moment it appears, and the next is 
lost. There is in our minds the same discrepancy as to 
whether we see it or not, as this patient manifested when 
asked whether she felt or not. Her contradictions were a 
proof of the obscurity of her sensations, and her convictions 
fluctuated between certainty and uncertainty, no doubt 
because the evidence was to her equivocal. 

The lesion began apparently in the membranes, and 
thence extended to the cord, implicating the sensitive roots 
of the nerves. 

There was no history of any acute invasion, nor did the 
symptoms at any period indicate acute disease. 

The dura mater of the brain occasionally offers a similar 
form of chronic thickening. Though the morbid change must 
be referred to inflammatory action, the process must have 
been most gradnal ; so gradual, indeed, that the symptoms 
were only such as were referable to atrophy, although the 
exudation thickened the membranes and infiltrated the pos- 
terior columns. There was no rigidity or other form of 
spasmodic affection of the muscles, as might have been ex- 
pected in spinal meningitis. 

Whether the exciting cause of the meningeal inflammation 
was injury, exposure to cold, or a rheumatic condition of the 
blood, is uncertain. Thei^e was no change in the pericar- 
dium or valves to corroborate the opinion of its being rheu- 
matic. But, whatever the original cause, its course would 
be determined by the diathesis of the patient ; and hence in 
the treatment of such a case, we must determine not only 
the seat and character of' the local lesion, but also view it 
through the peculiarities of the constitution, whether gouty, 
rheumatic, scrofulous, or syphilitic. Unless we approach 
accuracy of diagnosis in both these respects, the therapeutics 
of the case may be no better dii-ected than the efforts of an 



240 DISEASES OF THE NERVOUS SYSTEM. 

engineer who should pour medicine down the funnel of his 
engine because the power fails in the piston. 

It is probable that at any early period this case would 
have been benefited by repeated blisters, and the continued 
mild use of mercury and iodide of potassium. 

The fatal accident was peculiar. The adhesions of the 
membranes prevented the movements of the cord in the 
sheath, and exposed it to stretching by any sudden motion 
of the spine. 

The sections of the cord (Plate III) show to what extent 
disorganisation may take place, and yet the cord serve as a 
conductor of the voluntary power. The changes at A, b, c, 
must have been present at the time of the accident, when 
the patient Wfis able to walk about quickly, and with no more 
than a shuffling gait and some dragging of the leg. 

Case 30. — Pain in hack and loins for a year ; ijrofuse hsematuria, 
followed after a month hy weakness of the legs, which gradually 
increased to complete paraplegia ; malignant disease of lumbar 
glands and of the right kidney, extending into the bodies of the 
vertebne, and causing sloughing of the cord. 

Mrs. W — , fet. 58, a poor needle-woman, overworked, and but scantily 
fed, was admitted into Guy's Hospital, December 5tb, 1857, under the care 
of Dr. Wilks, for partial paraplegia of the lower extremities. She had been 
confined to her bed for eight weeks. There was emaciation of the whole 
body, but especially of the muscles of the legs, which were loose and flabby. 
She was just able to stand, but not to walk. The back was straight. No 
abnormal protrusion of any of the spines of the vertebrse. For a year she 
had had great pain across the loins and back, with some indefinite tender- 
ness. This was at first supposed to be due to her sedentary habits, and then 
to rheumatism. A month before her legs began to fail her she had profuse 
hsematuria, which was thought to arise from calculus in the kidney. After 
her admission into the hospital the parajilegia gradually became complete, 
without any preceding rigidity or involuntary jactitation of the legs. The 
integuments over the sacrum sloughed, and a similar tendency was mani- 
fested over the sides of the knees, from one leg resting on the other. She 
died exhausted January 20th, 1858. 

Post-mortem examination. — The outside of the theca vertebralis was 
covered with a thin layer of greyish offensive pus. The last dorsal and the 
three upper lumbar vertebrse were infiltrated with cancer extending from 
the lumbar glands. The body of the first lumbar vei-tebra was sloughing. 
The sloughing process had thence extended to the adjacent portion of the 
theca vertebralis, and to the body of the cord, which was ash-coloured, and 
entirely disintegrated, from the eighth lumbar vertebra to the filum termi- 



CASES OF PARAPLEGIA. 241 

nale. Several broad cartilaginous laminae in the lumbar arachnoid. No 
inflammatory exudation within the theca. Above the eighth dorsal vertebra 
the cord was remarkably pale and flaccid. No discoverable exudation 
among the tissue. The right kidney was enlarged by cancerous deposit. 
Left kidney healthy. Uterus and liver healthy. Cancerous tubera on and 
under the pleura of both lungs, and cancerous deposit in some of the 
bronchial glands. 

Case 31. — A tvrench of the neck followed after six months by a " stitch " 
in the neck, supposed to he neuralgic; extensive development of 
cancer about the upper d,orsal vertebrte, throughout the right lung, 
up the back of the neck under the deep muscles, and imvards between 
the laminx of the vertebne ; paralysis of the arm and right leg ; 
softening of the cervical portion of the cord; death sudden. 

Robert P — , set. 34, a farm labourer, was admitted under va\ care, 
August 5th, 1858, for jmralysis of both arms and of the right leg. Intelli- 
gence perfect. The account he gave of his illness was that six months 
previously he was taken with a " stitch " in the neck under the right ear. 
The pain "was so bad, it almost crazed him." After a short time the pain 
extended to the left side of the neck towards the occiput, and thence down- 
wards between the shoulders into both arms and into the legs. The pain 
under the left scapula was for a time very distressing. When he had 
suffered thus for four months, the left arm began to get numb and power- 
less from the shoulder downwards. He continued able to walk about very 
well until three weeks before his admission, when the right arm also and 
the legs began to fail him. The sphincters retained their power for a 
fortnight longer. On admission, both arms from the shoulders were power- 
less, but he could move the fingers slightly. Loss of sensation almost 
complete throughout both arms. Eight leg paralysed, left moved with 
some freedom. Loss of sensation as high as the fourth intercostal space. 
Left chest uniformly enlarged and universally dull on percussion, including 
the sternal region. Heart displaced to the right side. Respiration per- 
formed entirely by the right lung. Diaphragm and ribs moving freely on 
this side. Movements of head and neck without pain. Spine straight. 
No pain in any part. Respiration 44. Pulse 120. The following day, 
August 6th, at I r a.m., the breathing became much embarrassed, and he 
died quite suddenly at 2 p.m. After the post-mortem examination the 
friends gave an account of his having wrenched his neck about a year 
before in throwing hay into a loft. 

Post-mortem examination. — The left chest equally distended, and the 
heart displaced to the right side by the development of medullary cancer in 
the left lung. With the exception of a pai't of the centre of the lung, the 
pulmonary tissue was entirely destroyed. The pleura was thickened and 
cancerous, and firmly adherent to the ribs. In the right lung there was a 
tumour of the size of an orange, having the usual characters of fungus 
hsematodes. The cancerous growth had a firm attachment to the anterior 
part and sides of the body of the third dorsal vertebra, and extended 

16 



242 DISEASES OF THE NERVOUS SYSTEM. 

upwards on both sides of the neck, under the deep muscles, as high as the 
third cervical, and inwards between the laminae, so as to come in contact 
with the theca vertebralis. The theca was thickened, and the trunk of the 
fourth cervical nerve invaded on the left side. Unfortunately there was 
no opportunity to dissect the nerves of the brachial plexus, to determine 
their relations to the disease outside the vertebral canal. The cervical 
enlargement of the cord was swollen and softened, and granule-cells were 
scattered through its tissue. This change had apparently advanced into 
the cord from the right side of the neck. There was no cancerous deposit 
inside the theca vertebralis. The arachnoid had its normal appearance. 
It was the substance of the cord only which had begun to siiffer from the 
proximity of the new growth. Head not examined. Viscera of abdomen 
healthy. 



Case 32. — Gradual loss of poiuer in right arm, and subsequently in left ; 
after two months and a half, partial paralysis of legs ; breathing 
diaphragmatic ; frequent vomiting ; pulse quick and feeble. Death 
by exhaustio7i, after seven months. Strumous tubercle in the lower 
half of the cervical enlargement of the cord. 

Elizabeth W — , when eight months old, began gradually to lose the use 
of the right arm. After a fortnight the left became weak in a similar way. 
She came under my care as an out-patient at Guy's Hospital, April 13th, 
1857, when the paralysis had lasted two months. The wasted arms then 
hung loose and useless. The head was retracted between the shoulders ; 
the neck stiff. The legs were weak, but could be moved voluntarily. 
The muscular system generally was wasted, but of the arms most. The 
skin was constantly warm and freely perspiring. Occasional vomiting. 
Quick, very feeble pulse. A strumous swelling, the size of a small nut, 
was noticed in the skin of the right arm. A distinct history of struma on 
the father's side. The diagnosis was of tubercular deposit in or about the 
cervical portion of the cord. At the early part of May the right knee 
became swollen from effusion into the synovial membrane, and from this 
date both legs became partially paralysed. There were frequent spasmodic 
contractions in both legs, but most in the right, which was the weaker. In 
June the breathing was hurried and entirely diaphragmatic. Vomiting 
frequent. Difficult deglutition. Diarrhoea. During June and July vomit- 
ing and diarrhoja continued. There was great heat of skin. Profuse per- 
spirations. Ammoniacal urine. Pulse 140. Respiration 40. The long 
muscles of back became atrophied. Shoulders drawn up by the elevator 
muscles of the scapiilaj. There still at this time remained traces of volun- 
tary movements in the legs. She died, September 12th, from emaciation 
and exhaustion. 

Post-mortem examination. — Only the cervical portion of the cord was 
allowed for examination. The surrounding structures were healthy. The 
cord itself, in the lower half of the cervical enlargement, opposite the 
origin of the sixth and seventh cervical nerves, appeared to be enlarged. 



CASES OF PAEAPLEGIA. 243 

This enlargement arose from the presence of a strumous tubercle, which at 
this part had caused complete absorption of the proper tissue of the cord. 
This formation seemed to have had its origin in the right posterior and 
postero-lateral columns, thence extending by successive deposits, until the 
cord was gradually destroyed, only slight traces of the anterior columns 
remaining where the tubercle was largest. The chief part of the tumour, 
from the centre outwards, was opaque, yellow, and friable ; it consisted of 
granules, decaying nuclei, cells, and fat. This opaque dead part was 
surrounded by a transparent thin layer of more recent exudation, consisting 
of granules, nuclei, and imperfect fibre-cells, with no free oil-globules. 
Above the tubercle the two layers of arachnoid were firmly adherent, and 
by contraction had constricted the cord. Just below the tubercle the 
substance of the cord was so soft that it did not retain its form when 
unsupported by the membranes. 

Remarhs. — The gradual onset of the paralysis in this case, 
and its gradual extension until both arms became paralysed, 
obviously indicated a progressive organic change in the 
cord. The nature of this change was also to be plainly in- 
ferred from the hereditary tendencies through the father's 
side, and from the actual presence of a strumous formation 
in the arm. 

That during the earlier stages of its course the disease 
should have been one of cervical paraplegia, the power over 
the lower extremities continuing after the arms were para- 
lysed, accords with what has been noticed in other cases ; but 
when instead of central disease the lesion primarily affects 
the external parts of the cord, at least of the anterior col- 
umns, the legs suffer first, and often exclusively if the lesion 
be moderate. 

It is a matter of regret that the state of the sensibility of 
the legs was not determined. Perhaps, from the age of 
the child, it could not have been determined. 



PLATE II. 

Fig. I. — Transverse section of the spinal cord in tlie dorsal region (Case i8, 
p. 216), showing atrophy of the grey substance, and inflammatory degenera- 
tion of the columns. 

The atrophy did not affect the caudate vesicles. These, by a higher 
power, were seen to have their normal structure. The white substance was 
symmetrically degenerated from chronic inflammation. The exudation cells 
had undergone fatty degeneration, and were incrusted with fat-globules. 
The capillaries are seen to be similarly incrusted, producing irregular white 
lines. The symmetry of the lesion was very exact. It included a small 
portion of the anterior columns on either side of the anterior fissure, the 
posterior half of the lateral columns, and the centre and posterior portion of 
the posterior columns. The part of the posterior columns adjacent to the 
posterior horns of the grey substance was normal. There was no exudation 
amongst the grey substance. The apparent traces of such, seen in the 
drawing, are caudate vesicles. 

The artist has not strictly drawn the granule-masses according to scale, 
but he has faithfully rendered the general appearance of the section under a 
low power. 

Figs. 2 and 3. — Transverse sections of the cord (Case 19, p. 219) showing 
degeneration of the posterior columns from chronic inflammation. 

The anterior and antero-lateral columns, and the grey substance, were 
normal. The upper section (fig. 2) is from the upper cervical region ; the 
lower (fig. 3) from the lower dorsal region. The granular appearance was 
due to fatty degeneration of the inflammatory exudation. Though the 
ai-tist has exaggerated the relative size of the granules to the columns for 
distinctness' sake, he has strictly maintained their relative distribution. The 
lesion was remarkable from its being so entirely limited to the posterior 
columns, though it affected them throughout their own length. 



PLATE II. 




Adlard and Son, Imp. 



Fig. I, Case i8, p. 216. 
Figs. II, III, Case 19, p. 219. 



PLATE III. 

Transverse sections of the cord and its membranes, Case 29, p. 236. 

A. Section through upper part of the cervical region. The left side of the 
cord was here distorted by the development of a cyst in the grey substance. 
A smaller cyst of the same kind existed in the grey substance on the right 
side, but at a lower level, so that only a trace of it is visible in this section. 
These cysts had distinct walls of fibrous tissue and condensed nerve- 
substance. They contained clear colourless fluid. 

B. Section through upper part of the cervical enlargement, showing great 
thickening of the membranes, and degeneration of the posterior columns and 
grey substance, including also the posterior roots of the nerves, with the 
development of common white fibrous tissue in place of the normal 
structfires. 

c. Section about the middle of the cervical enlai'gement. The membranes, 
and especially the dura mater, extremely thickened. This change was 
greatest on the posterior surface of the cord, where the membranes were 
adherent together. Tlie posterior columns, the grey substance, and the 
posterior roots much degenerated. Some of the normal structure of the 
posterior columns is seen lying embedded in a stroma of fibrous tissue. 

These changes were due to chronic inflammation, apparently advancing 
from the membranes into the substance of the cord. 



PLATE III. 




Case 29, p. 236. 



^Jlard andSon, Imp. 



CASES OE PARAPLEGIA 



ASSOCIATED WITH 



GONORRHCEA AND STRICTURE OF THE URETHRA.' 



In the year 1833 Mr. Stanley read before the Society some 
cases of paraplegia arising from primary disease of the urinary 
organs. 

According to the views expressed by him, disease of the 
kidneys may produce a morbid impression upon the cord 
through sentient nerves, which, being reflected outwards to 
the extremities, may occasion an impairment of both motion 
and sensation, and pai-aplegia result without organic lesion 
of the cord itself. 

It would require a more minute examination of the cord 
than was made in the cases given in the paper referred to 
before the important negative assumed in their explanation 
could be regarded as established, since it is known that the 
structure of the cord maybe extensively disorganised where 
an experienced observer, without the aid of the microscope, 
may fail to discover the traces of disease. In proof of this I 
may quote the following case, which was under the care of 
my friend and colleague, Mr. Hilton, Avho has kindly placed 
it at my disposal. 

Paraplegia following gonorrhoea and S2jphilis ; inflammation of the sub- 
stance of the cord ; no traces of lesion discoverable without the micro- 
scope. 
James L — , set. 20, admitted into Guy's Hospital Marcli 14th, 1855; a 
gentleman's servant, unmarried. Always had good health until he con- 
tracted gonorrhoea and had a chancre eight months ago. He was under 

' Reprinted from the ' Medico-Chirurgical Transactions,' 1856, p. 195. 



248 DISEASES OF THE NERVOUS SYSTEM. 

treatment for three months. After the chancre had healed he again became 
infected, and ulceration followed at the seat of the old cicatrix. For this he 
was again under treatment until the beginning of the year 1855. -^^ ^^^^^ 
time (January i8th), having occasion to go from home, he slept, as he 
thinks, in a damp bed, and three days afterwards began to have pains and 
weakness in the legs and about the neck and occiput. 

On the 26th he had a rigor, and the weakness of the legs was rather 
suddenly increased, with loss of sensation above the ankles and formication 
in the feet. Incontinence of urine came on at the same time. 

On the 28th he managed to get downstairs with the help of his mother 
and the use of a crutch, but at night he had lost all power in the legs, and 
was carried to bed. During the next fortnight the loss of sensation 
gradually extended upwards to a line corresponding to the distribution of 
the ninth dorsal nerve. The sphincters were paralysed. The susceptibility 
to the excito-motor movements continued to increase, and the cord at length 
became so irritable as to occasion the patient great distress ; the least 
agitation or the slightest touch bringing on violent spasmodic contractions 
of the legs, though the irritation was quite unfelt. There was a painful 
sense of constriction across the chest. Bedsores formed and rapidly 
extended. 

There was no important change in his symptoms until April i8th. The 
ui'ine was ammoniacal and continually dribbled from him, excoriating the 
scrotum and inner parts of the thighs. The bedsores sloughed. There 
were frequent involuntary spasms of both legs, but especially of the left. 
At this date he began to have cough, headache, and more frequent rigors. 
Tongue became furred. Pulse accelerated. 

He died rather suddenly. May i6th (four months from the beginning of 
his symptoms), having during the last month become much exhausted from 
frequent rigors and hectic. 

On a sectio cadaveris the vertebral canal was healthy. On opening the 
dura mater the two layers of arachnoid were found united, as usual, on the 
posterior surface of the cord by delicate adhesion. There were some osseous 
plates on the visceral layer of the membrane. No traces of vascular injec- 
tion or of inflammatory exudation. The cord had the normal size and 
appearance, and neither to the touch nor on section presented any obvious 
softening. With a lens of an inch focus the surface of the columns at and 
below the origin of the sixth nerve had a mottled appearance, some portions 
being opaque and yellowish ; and a more minute microscopical examination 
discovered extensive disorganisation of the nervous structure, the focus of 
the morbid change being at the middle of the dorsal region and principally 
in the anterior columns. The fibrous structure was loose, and amongst it, 
and apparently resulting from its disorganisation, were numerous oily 
granules, together with a great number of the characteristic mulben-y 
masses (granule-cells). Sections of the cord at the lower part of the dorsal 
and in the cervical region gave the same results, but in a less degree. 

This proves that we ought to look with great mistrust 
upon the evidence which the unassisted eye supplies in the 



CASES OF PAEAPLEGIA. 249 

examination of nervous structures, where but slight lesions 
produce such decided and striking symptoms. 

The following cases seem to show that, instead of regard- 
ing the nerves as the channels through which the cord is 
secondarily affected in disease of the urinary organs, we 
ought rather to look to the veins or the blood itself as the 
means by which the lesion is propagated, and, instead of at- 
tributing the paraplegia to functional depression of the ner- 
vous energies, to refer it to inflammatory changes. 

In the following case this pathological relation certainly 
existed. For the particulars of it I am indebted to my friend 
Dr. Habershon. 

Paraplegia ; acute spinal arachnitis and softening of the cord following 
retention of urine from stricture. 

William W — , set. 29, a cabman, admitted into Guy's Hospital on Sunday 
morning, September 19th, 1847, for retention of urine and stricture, to 
which he had been subject for several years. After a warm bath, and with 
some difficulty, the smallest catheter was passed and the urine drawn off. 
On the following day he had again difficulty in emptying the bladder, and 
twenty leeches were applied to the perinseum. From this date until the 28th 
the stricture was dilated daily, and he was going on favorably, being a con- 
siderable part of the day up and about the ward, ajsparently in his usual 
health. On the 28th he complained of a fixed and constant pain near the 
angle of the tenth rib on the right side, for which a blister was applied, with 
relief. Three days after (October ist) he was free from pain, but feverish. 
He dressed himself as usual and sat by the fire ; but, on attempting to 
return to his bed in the afternoon, he suddenly found his legs weak and 
numb. Pulse 120. Tongue thickly furred. He was freely purged without 
benefit. On the 3rd the loss of sensation and motion was complete in both 
legs, and sensation was imperfect on the surface of the abdomen as high as 
the umbilicus. He had no pain in the spine, nor any convulsive movements 
of the legs. The bladder was emptied morning and evening by the catheter. 
In the intervals it dribbled away, highly ammoniacal and purulent. 
jVIr. Key, under whose care the patient had been admitted, saw him on the 
5th, and considered the paralysis to depend upon thickening of the posterior 
common ligament. 

He gradually became more prostrate. A large slough formed over the 
sacrum. The evacuations passed involuntarily. He expired on the 27th, 
one month from the commencement of the spinal symptoms. There was no 
affection of the brain throughout. 

Sectio cadaveris. — Head not examined. On removing the cord with its 
membranes from the canal a small quantity of pus was found lying on the 
outside of the sheath, opposite the bodies of the sixth, seventh, eighth, and 
ninth dorsal vertebrae, and one of the veiiebral veins in the lumbar region 



250 DISEASES OF THE NERVOUS SYSTEM. 

was full of well-formed pus. The spinal fluid was densely coagulable. The 
arachnoid was thickened and presented traces of recent inflammatoiy 
exudation. The dorsal portion of the cord was very distinctly and generally 
softened. Lungs healthy. Pericardium contained a small quantity of fluid, 
with a patch of fibrin upon the ventricle. Liver healthy. Kidneys large 
and congested, with spots of ecchymosis. Secreting structure coarse and 
soft. Pelves dilated ; their mucous membrane and that of the ureters and 
bladder injected and covered with purulent exudation. An old stricture 
existed at the commencement of the membranous portion of the urethra, 
and several false passages, one opening into an abscess behind the bladder, 
and two returning into the bladder. The vesical veins in the neighbourhood 
of the pelvic abscess were thickened and partially obstructed by recent 
lymph. No traces of peritonitis. Intestines healthy. 

Here phlebitis was no doubt caused by the catheterism, 
but in the following cases gonorrhoea probably brought on 
paraplegia as one of its proper sequoias, after the manner in 
which its other secondary affections, as swelling of the joints^ 
are produced. Whether this be through a purulent infection 
of the blood, or through some more specific taint, is yet 
unknown. 

Paraplegia, with softening of the corcl , folloiving gonorrhoea and chronic 

gleet} 

Henry F — , set. 21, a pale and delicate man, a shoemaker. Habits 
irregular. Has had gonorrhoea many times, and is subject to a permanent 
gleet, increased when he indulges in drink. His general health has been 
good; and he was, so far as he knows, quite well on Tuesday morning, 
March ist, 1853. In the afternoon of that day he began to have pain 
between the shoulders, and a diarrhoea came on, to which he had been fre- 
quently subject. This continued during the night, with increased pain in 
the back and spasmodic tremblings in the legs. Towards morning the legs 
became weak and numb, and he was iinable to void his urine. His friends, 
for his relief, applied hot fomentations to the feet, legs, and pubes, which 
produced extensive vesication. He was brought to Guy's Hospital, 
March 4th, and admitted under the care of Mr. Bransby Cooper, with the 
following symptoms : — complete loss of motion below the sixth dorsal 
vertebra ; the muscles of the seventh intercostal space do not act in respira- 
tion ; sensation perfect above the line indicated, but on the abdomen 
pinching or pricking the skin gives no pain, and only the faintest sensation ; 
in the legs there is complete amesthesia ; bladder distended, with dribbling 
of urine; great exhaustion; pulse no, weak; respiration tranquil, 24; 

' Cf. a lecture on Urinaiy Paraplegias in the New Sydenham Soc. 
vol., 1881, 'On Diseases of the Nervous System,' by T. M. Charcot, p. 252, 
in which this case is quoted. — Ed. 



CASES OF PARAPLEGIA. 251 

febrile heat ; tongue injected ; complains much of thirst. Spine quite 
straight. A slight degree of tenderness and some sense of stiffness between 
the shoulders. At the epigastrium and about the penis, thighs, and ankles 
the integuments are vesicated and the skin is in parts sloughing, from the 
hot fomentations which have been applied ; and last night, in addition, 
several bullje formed spontaneously on the left ankle and on the soles of 
the feet. No bedsore. Fjeces healthy, passed involuntarily. Urine drawn 
off by the catheter, ammoniacal, and containing mucus and pus, with 
traces of blood. 

He died exhausted from irritative fever and sloughing, March 15th, a 
fortnight from the beginning of the paraplegic symptoms. 

Sectio cadaveris. — Several superficial sloughs over the legs and abdomen. 
Large sloughing bedsore over sacrum. Bullae on the soles of the feet. 
Bones and ligaments of the spine healthy. The cord was generally softened 
as high as the middle of the dorsal region, at which point the nervous sub- 
stance was broken up by the gentlest stream of water falling on it. The 
grey and white portions appeared to be equally affected. Amongst the 
softened nerve tissue granule-cells were abundant. There was no point of 
suppuration, nor any trace of old disease in the cord. The membranes were 
apparently healthy ; liver healthy ; kidneys of a dark colour, from venous 
congestion ; the mucous membranes of the pelves slightly ecchymosed ; 
bladder thickened, the lining membrane covered by recent diphtheritic 
exudation. Between the bladder and rectum there was an irregular abscess, 
with sloughing walls, communicating with the bladder by a large perfora- 
tion of its coats. Near the bulb was a more recent abscess, filled with 
healthy pus. The lungs collapsed freely on opening the chest, and were 
free from disease. Heart healthy. 

Paraplegia occurring with gonorrhoea ; recovery. 

Alfred L — , set. 28, a thin, pale young man, below the middle stature, 
employed in a ready-made shoe warehouse. His habits are rather irregular, 
but yet he has had no illness until the present attack. On the 17th of June, 
1855, he took a gonoiThosa, attended with the usual symptoms, until four 
days ago, July ist, when he began to feel pain between the shoulders, 
which he attributed to cold, though he knew of no exposure. The follow- 
ing day the pain had increased, and extended to the loins, but was not such 
as to prevent his going on a Sunday excursion to Brighton. On reaching 
town in the evening he walked to his home, the distance of a mile and a 
half, without feeling any weakness in his legs. The next day (July 3rd) he 
was at his work, but felt very unwell, and his legs weak ; he had some 
difficulty in emptying the bladder. In the evening he applied a mustard 
poultice to the loins, and passed a quiet night. July 4th he was unable to 
leave his bed, and sent for my friend Mr. Roper on account of retention of 
urine. Dui-ing the day the legs became weaker, and in the evening he 
again required the use of the catheter, and his evacuations passed from him 
involuntarily. July 5th he was admitted into Guy's Hospital, under my 
care. He could move the legs only very feebly ; numbness along the outer 



252 DISEASES OF THE NERVOUS SYSTEM. 

part of the thighs as far as the knees ; involuntary muscular twitchings in 
both legs ; abdomen flaccid, a sense of constriction around the lower part ; 
inability to empty the bladder ; constipation ; no tenderness in the spine ; 
no affection of the joints. Tongue moist, slightly furred ; skin cool ; 
pulse 76. Moderate gonorrhoeal discharge. 

By cupping, laxatives, and counter-irritation, the paralytic symptoms 
slowly disappeared, and on the 15th he was able to stand without help, 
though not to walk. A third blister was applied to the loins, and medicine 
continued, until he became impatient to return home. When he left the 
hospital he had but slight weakness in the legs. The gonorrheal discharge 
had gradually ceased. 

He continued to attend as an out-patient for a month, and was then 
apparently well. 

I saw nothing more of him until July, 1856, when he again applied on 
account of a slight return of his spinal symptoms, of which he maintained 
he had no traces until the occurrence of the gonorrhoea. 

By a return to his former treatment he again improved, and is now well. 

That the occurrence of paraplegia with gonorrhoea is due 
to an inflammatoiy affection of the cord is further made pro- 
bable by one at least of Mr. Stauley^s own cases, which I 
may perhaps be allowed to quote in this place : 

" A man, set. 30, was admitted three weeks previously on account of 
gonorrhoea, with phimosis, which was in progress towards cure ; the inflam- 
mation in the urethra had subsided, but the discharge continued. Whilst in 
this state as far as the local disease was concerned, and without any particular 
derangement of the general health, he was suddenly seized with paraplegia, 
which extended as high as the umbilicus. In the limbs the loss of motion 
was complete, and the loss of sensation nearly so ; the functions of the 
brain were unaffected. On being questioned, he stated that he had been 
suffering for a day or two from pain in the loins. The pulse was 85, and 
rather full. He was cupped in the loins, and free action of the bowels 
obtained by purgatives, but with no benefit. The urine flowed involuntarily, 
and in considerable quantity. As, however, it was thought the bladder was 
distended, a catheter was introduced, and three pints evacuated. In sixteen 
hours from the attack of paraplegia the man suddenly fell back in his bed 
and died. The spinal cord was first carefully examined. There ivas found 
some turgescence of the vessels, both in the membranes and substance of its 
lumbar 2')ortion, and a few drachms of transparent fluid in the theca ; 'but,' 
says Mr. Stanley, ' neither the turgescence of vessels nor eft'usion of fluid 
was sufficient to explain the paraplegia by pressure on the cord.' The liver 
was enlarged and indurated. The other abdominal viscera, with the excep- 
tion of the kidneys, were sound, and with no unusual turgescence of the 
vessels. Both kidneys were of so dark a colour as to be almost black ; they 
were remarkably flaccid, and, on sections being made of them, were found to 
be in every part gorged with blood. Tlie mucous membrane lining the 



CASES OF PARAPLEGIA. 253 

infundibula and pelves was dark -coloured, from the turgescence of the 
vessels. The coats of the ureters and the mucous membrane lining the 
bladder were also very much more loaded with vessels than is usual. In the 
bladder was about a pint of urine. Some fluid was found between the 
membranes of the brain and in its ventricles." 

The objection made by Mr. Stanley that the turgescence 
of the vessels and the effusion of fluid were insufficient to 
produce paralysis by pressure is no doubt valid, but it 
equally applies to a large proportion of the cases of 
paraplegia from inflammation of the structure of the cord. 
It is not often the amount of exudation which by its mechan- 
ical action determines the paralysis, but rather the coin- 
cident changes in the nervous tissue from defective nutrition 
and softening. The small amount of exudation, and the 
apparently slight changes of structure which accompany the 
inflammatory lesions of the cord, is one of the most remark- 
able points in their history ; and here it is, as I wish to 
prove, that the microscope has so much aided our investi- 
gations. With the knowledge we have so obtained, the 
injection of vessels in the structiire of the cord must be 
considered an important indication of organic lesion, and 
can leave us in but little doubt that the paralysis was the 
result of disease of the cord, rather than of any simply mor- 
bid impression made upon it through incident nerves. 



ON 

PARALYSIS OF THE LOAVER EXTREMITIES, 



CONSEQUENT UPON 



DISEASE OF THE BLADDER AND KIDNEYS. 
(URINARY PARAPLEGIA.)' 



It is admitted as an established fact in medicine that 
paralysis of the lower extremities is occasionally caused 
by diseases of the urinary organs ; but observers are not 
agreed upon the state of the spinal cord in these cases, nor 
upon the character of the morbid processes by which the cord 
is affected. 

The diagnosis of urinary paraplegia is not free from some 
fallacies. These have not been sufficiently recognised by 
writers, or rather they have been passed over altogether. 
The evil of this course has been great, since it has vitiated 
the general conclusions arrived at. The cases recorded 
need a winnowing criticism. If they had received it, 
the clinical history of urinary paraplegia would have had 
a more secure basis, and there would have been no room for 
this communication. 

Urinary paraplegia, as the name implies, is paralysis set 
up by disease beginning in the urinary organs. 

' Reprinted from the 'Guy's Hospital Reports,' 1861, p. 313. 



PARALYSIS OF THE LOWER EXTREMITIES. 255 

The first difficulty in tlie diagnosis is to distinguish the 
true order of the morbid processes from that which they 
superficially pi'esent to our notice. 

We require but little clinical experience to inform us 
that symptoms and lesions may become apparent to us in an 
order very different from their true one ; and that we cannot, 
without collateral proof, determine what the true order is. 
So fallacious is often the apparent relation of phenomena, 
that it may tax the most matured experience to avoid error. 

We might refei", in illustration of this, to the history of 
cerebral disease. It is notorious that organic affections of 
the brain may for months or years lie latent, and bewilder 
us with peripheral symptoms, and particularly with every 
variety of gastric disturbance, until some definite and often 
sudden warning from the brain unmasks the truth to us, 
and proves how erroneous our thoughts have previously 
been. 

It is not always easy to determine at the outset whether 
symptoms have a peripheral or central origin. In para- 
plegia associated with disease of the urinary organs, the 
difficulty is perhaps greater than elsewhere ; yet it has been 
tacitly assumed that, if cystitis or other lesion of the 
bladder. precede paralysis of the lower extremities, we are to 
infer that the paralysis has had a peripheral oi'igin, and has 
been occasioned by the peripheral lesion which first promi- 
nently arrested our attention. This, at least, is the 
conclusion which must be drawn from such a statement as 
the following : 

" To give at once,^' says Dr. Brown-Sequard, '' an idea of 
the striking differences between the kind of paraplegia 
which deserves the name of reflex and one of the forms of 
paraplegia of centric origin, we will condense in the following 
table^ the principal features of two of the most characterised 
varieties of reflex and centric paralysis of the lower limbs — 
i. e. of paraplegia due to a disease of the urinary organs, and 
paraplegia due to myelitis." 

He goes on in the table to say that urinary pai'aplegia 
is preceded by an affection of the bladder, the kidneys, or 

^ 'Lancet,' April, i860. 



256 DISEASES OF THE NERVOUS SYSTEM. 

the prostate, whilst in paraplegia from myelitis there is no 
disease of the urinary organs, except as a consequence of the 
paralysis. 

Taken thus generally, nothing is more untenable than 
this statement. We might equally maintain that gastric 
affections which lead off the course of symptoms in diseases 
of the brain are the cause of the cerebral disease, as that 
the urinary affection is the cause of the paraplegia which 
it precedes. Disease of the bladder, prostate, or kidneys 
may be the cause of paraplegia ; but it is equally true that 
affections of the bladder, kidneys, or prostate may be the 
prelude of a paraplegia from myelitis. Therefore, so far as 
precedence of symptoms goes, nothing can be inferred from 
that fact alone. There is, indeed, one form of paraplegia, 
which usually begins with symptoms of catarrhus vesicas, 
namely, that form which depends upon cerebro-spinal 
exhaustion from mental overwork. We see the distant 
threatenings of it, and happily for the most part only distant, 
in the faintly alkaline urine, turbid from the phosphate of 
lime, and attended with lumbar malaise, which comes before 
us almost every day in this overworked metropolis. 

As an example of this form of paraplegia the following 
case may be here recorded : — A gentleman get. 54, of anxious 
temperament, and engaged as manager of a public company, 
consults his medical attendant for a deposit of mucus in the 
urine. There appear to be no other symptoms to arrest 
attention. The gait is firm, and a day^s shooting can be 
taken over the country without unusual fatigue. Nothing- 
is discovered at this stage of the case to account for the 
cystitis, but various theories are suggested. Amongst 
others, it is attributed to a gouty affection of the bladder, 
or to a calculus in the kidney. These explanations seem 
the more probable from the occurrence of flying pains in 
the lower extremities. Months go on, the vesical discharge 
continues, but there is no suspicion of its being due to a 
morbid state of the cord. The legs show no distinct 
weakness. The stomach becomes irritable. With this new 
development of peripheral symptoms, there is still no 
suspicion of any affection of the cord. Two years from 
the commencement of the disease of the bladder, and some 



PARALYSIS OF THE LOWER EXTREMITIES. 257 

montlis after the irritability of the stomach began, the lower 
extremities became weak; and now for the first time it was 
suspected that a failing state of the nervous centres had 
given rise, from the beginning, to the vesical and gastric 
symptoms, and were themselves indeed the first evidence of 
such a failure. Other symptoms, previously unnoticed, could 
now be observed ; the contracted pupils, the occasional 
vertigo and headache, the inability to apply the mind with 
vigour, and the wandering rheumatic (?) pains. Arrived at 
this stage, the case exhibited an instance of paraplegia, in 
which the earliest effects of the paralysis were evinced, 
through the sympathetic, upon the bladder and stomach, as 
a flow of tears follows an emotional affection of the brain. 

It is no new fact in medicine that cerebral exhaustion 
may impair the functions of the cord (especially of its lower 
segments), and give rise to precisely those symptoms which 
have been set down as pathognomonic of urinary paraplegia. 
Illustrations might be multiplied in support of this asser- 
tion; but, as common experience will supply such, they need 
not be introduced here. I cannot, however, refrain from 
referring to one other case, in which severe dyspepsia 
preceded for a long time the symptoms of paraplegia from 
myelitis. It occurred in a man aet. 58, whose nervous power 
had been depressed by much mental distress. Together 
with the gastric pain and irritability, there was in the urine 
a large deposit of uric acid. Dyspepsia and these uric acid 
deposits continued from autumn to the spring of the follow- 
ing year before any weakness of the legs became evident. 
There was not then complete paralysis. The legs were only 
very weak, and the degree of weakness was variable. For 
many months the progress of the case was marked by similar 
fluctuations, until at length the paraplegia was complete. 
Sensation was never diminished ; but, on the contrary, there 
was in the early stage of the case an over- sensibility of the 
surface. On a post-mortem examination the entire substance 
of the cord, in the middle of the dorsal region, was softened 
almost to diffluence. 

A recognition of this common source of error, in respect 
to the true order of the morbid processes, lies at the 
threshold of the diagnosis of urinary paraplegia. There is, 

17 



258 DISEASES OF THE NERVOUS SYSTEM. 

perhaps, no fact to be more insisted upon than the dependence 
of the normal functions of the sympathetic upon the 
integrity of the spinal system. As a result of this depend- 
ence we learn that dyspepsia, vomiting, constipation, colic, 
vesical catarrh, prostatic irritation, pains in the joints, and 
many other peripheral disturbances, may seem to precede the 
central malady, and to be the cause of it, when in truth they 
are its effects. 

It would not be difficult to point out examples of this 
clinical fallacy of hysteron proteron in the writings of even 
great authorities. In reference to the present subject, we 
might instance the cases of paraplegia said to be due to 
enteritis; nor should we be deterred from quoting them as 
examples of this error, though supported by such authority, 
since science recognises no authority but that which is based 
upon evidence. Striking as such cases at first perusal seem, 
they fade away under inquiry, and take no rank as established 
truths. The existence of enteritis, assumed as the active 
cause in these cases, is itself more than doubtful, and the 
paraplegia said to have ensued from it is supported by no 
better evidence. 

There is a second source of error not alluded to by 
writers on urinary paraplegia. As if anxious to prove the 
existence of the disease more by bulk of evidence than by 
the character of it, they accept the mere muscular weakness 
which is often associated with prostatic and vesical disease 
for partial paraplegia. A perusal of the treatise of Leroy 
d'Etiolles, jun.,^ to which such frequent reference is made, 
will bear out this statement, if we may accept his words at 
their strict value. Whilst at the heading of many of his 
cases there is the word " paraplegia,^' in the subsequent 
details of them we find no further evidence of paralysis than 
may be gathered from such expressions as the following : — 
^' faiblesse dans les jambes ;" " faiblesse des membres, telle 
qu'elle ne permet plus au malade de se tenir debout sans 
appui ;" " qu'il ne pouvait se soutenir sur ses jambes ;" " le 
malade se sent faible sur les jambes, et apres la moindre 
fatigue il eprouve des tremblements, il ne pent marcher sans 
le secours d'un baton ;" " affaiblissement des membres 
' ' Des Paraljsies des Membres inferieurs,' &c., Paris, 1856. 



PARALYSIS OF THE LOWER EXTREMITIES. 259 

inferieurs ;" " des tremblements/' &c. These expressions, 
though intended to convey evidence of paralysis, are not in 
themselves any proof of its existence. Nor does the perusal 
of many of these cases lead us to the conclusion that there 
was in reality any paraplegia at all. 

If we bear in mind how much the activity of the lower 
limbs depends upon an unfettered action of the abdominal 
and lumbar muscles, and of the psoee, iliaci and glutasi, we 
cannot but recognise a fertile source of "pseudo-paraplegia " 
in that impairment of muscular activity which necessarily 
attends the malaise of chronic pelvic affections, whether 
vesical or nterine. 

A perusal of the cases which have been recorded or quoted 
by authors, to establish the frequency of paraplegia from 
pelvic disease, will show that the error here pointed out has 
not been unfrequent. And since in these instances of what 
we here term " pseudo-paraplegia " the cord is not implicated, 
neither the recovery of the patient nor the absence of lesion 
after death can be brought in support of any theory of para- 
plegia properly so called. 

To those who are unacquainted with the difficulties of the 
subject, the existence of paraplegia in any case may seem a 
matter too obvious for discussion. There is, however, often 
difficulty, or at least necessity for care, in deciding whether 
there be paralysis or not. 

To illustrate this point I may record the following case, in 
which there was such universal muscular atrophy as to 
render the patient incapable of moving the lower extremities 
with any power or freedom, or of carrying the hands to the 
head. Although there was no paralysis, still the impression 
that it was a paralytic affection was at first so ob- 
viously suggested by the wasted and powerless limbs, 
that it needed a careful consideration of the facts to avoid 
falling into error. 

For the details I am indebted to Dr. Francis Hutchinson, 
of Blackfriars, with whom I saw the case, and who kindly 
obtained for me a post-mortem examination. 



260 DISEASES OF THE NERVOUS SYSTEM. 



Universal miiscular atrophy to an extreme extent {pseudo-paraplegia) ; 

anxmia. 

Mrs. C — , descended of a healthy family, was in good health until the age 
of thirty -two, when she lost her only child. From this time she became intem- 
perate, and continued her intemperate habits through many yeai-s. At the age 
of forty-one her muscular system rapidly emaciated. All useful power of the 
upper and lower extremities was lost ; the hands dropped at the wrists, and the 
feet could not be raised at the ankles. Except transient formication, return- 
ing at short intervals for a day or two, there was no affection of sensation, 
nor was there any pain. Under the use of tonics and galvanism there 
appeared to be some slight improvement. I saw her three months before 
her death ; she was extremely sallow. The whole muscular system was 
remarkably wasted ; she could not stand, nor even cany her food to her 
mouth without supporting one arm with the other. Sphincters good ; 
deglutition good. More or less general tenderness of the surface, but other- 
wise no hyperjesthesia, the tenderness being attributable to her attenuation. 
The special senses and the intellect unaffected ; speech good. 

During the two months preceding her death the hands recovered much of 
their power, so far that she could grasp a cup and raise it to her lips, but she 
could not pick up a pin or thread a needle. She was cheerful ; memory 
slightly impaired. There was at times that hallucination which occurs in 
the general paralysis of the insane. She often said she could walk about, 
and seemed to be unaware of her helpless state. At other times there was 
no intellectual disturbance, and that which is noted was difficult to detect. 
The sphincters were throughout unaffected, and the expression of the face 
betrayed no cerebral disturbance. Five days before her death febrile sym- 
ptoms set in, with slight wandering delirium. 

Although the first aspect of this case gave the impi'ession 
that it was one of paralysis from disease of the cord, there 
was in reality no paralysis at all. The dropped and extended 
feet and partially dropped wrists, and the thumb gently 
inclined to the palm, were owing to the muscles being too 
weak in their nutrition to counteract the mere force of 
gravitation. The case was strictly one of debility, and not 
of paralysis, if we may distinguish cases of diminution of 
voluntary power from simple insufficiency of muscular nu- 
trition from those of actual lesion of the nervous or mus- 
cular apparatus. The following were the post-mortem 
appearances : 

Post-mortem examination. — Cord small, especially at cer\acal and lum- 
bar enlargements ; texture firm ; no abnormal elements discovered in the 



PAEALYSIS OF THE LOWER EXTEEMITIES. 261 

tissue by the microscope. Membranes of cord healthy ; 'anterior roots of 
nerves normal. The anterior and posterior columns maintained their due 
proportion to the other parts of the cord ; head small ; calvarium very thick, 
especially at the frontal protuberances. Much clear subarachnoid efEusion, 
supplemental to the wasted brain; lateral ventricles rather large; septum 
lucidum very thin. The cerebral substance had throughout the normal firm- 
ness and appearance on section. The heart was small and flaccid, its tissue 
soft and easily lacerable, the right ventricle much loaded with fat ; the 
muscular fibre had not undergone fatty degeneration. The liver large and 
pale, more or less univei-sally cirrhosed ; kidneys normal. The voluntaiy 
muscles of the extremities and the intercostals were pale and wasted ; the 
fibrillae not fatty. 

Urinary paraplegia occurs but very rarely in women. 

It occurs more commonly in men, and generally as a con- 
sequence of long-continued chronic disease in the urethra 
and neck of the bladder. 

Children, though liable to calculus and the irritation 
consequent upon it, do not appear to suffer from urinary 
paraplegia. 

It is important to note that, except in acute gonorrhcea, 
urinary paraplegia does not occur until after the chronic 
affection of the urethra and bladder giving rise to it has 
lasted some time — often many years. The history com- 
monly runs thus : — " Stricture many years ; — frequent cathe- 
terism ; — at length numbness and tingling in legs, and 
imperfect paraplegia." Or, " Stricture ; — catheterism ; — 
intermittent febrile symptoms ; — and, subsequently (at an 
indefinite period) paraplegia." 

In some cases ten or more years have intervened from 
the commencement of the pelvic affection to the onset of 
paralytic symptoms in the legs. 

Urinary paraplegia is not known to follow the irritation 
produced by the passage of urinary calculi. 

Neither does it follow the casual introduction of a catheter 
or sound in exploring the bladder for a calculus. 

It rarely follows cases of primary pyelitis, whether pro- 
duced by renal calculi or by strumous disease. 

In unequivocal cases, by which I mean those in which the 
affection of the cord is directly referable to the pelvic disease, 
there is commonly pain in the back preceding the paralysis. 
But the pain in the loins may be absent even though there 



262 DISEASES OF THE NERVOUS SYSTEM. 

be acute inflammation about the coi'd. In one case^ the 
spinal veins were in a state of suppuration, but there was no 
pain in the back. It may be asserted, not of urinary para- 
plegia only, but also of inflammation of the membranes and 
substance of the cord occurring under other circumstances, 
that pain, in its presence and degree, is very variable ; and 
that it is more dependent upon the implication of the nerves 
in the canal, and of the muscles, bones, and ligaments Avhich 
surround the cord, than upon the state of the cord itself or 
its membranes. 

In many cases iri'itative fever precedes the development 
of urinary paraplegia, the febrile symptoms being often di- 
rectly referable to suppuration in or about the prostate or neck 
of the bladder. 

Commonly, only the lower extremities are affected. This, 
however, is not constant ; for the disease may extend up to 
an indefinite height in the cord. We cannot give a better 
instance of this than the case of Professor {Sanson, so often 
quoted. This celebrated French surgeon was for many 
years liable to prostatic irritation, for which sounds were 
employed and cauterisation. An ammoniaco-magnesian cal- 
culus formed in the bladder and was broken up. A year 
before his death (after years of suffering) he began to 
complain of numbness and painful formication in the gluteal 
region. In a short time there was complete loss of sensation 
in the lower extremities, and subsequently as high as the 
mamm^. Firm pressure or percussion over the upper dorsal 
vertebraG gave pain. The lower extremities became per- 
manently flexed and rigid, and violent convulsions came on 
in them, sometimes spontaneous, sometimes excited by 
tickling or pinching the feet, although the patient was not 
aware of the stimulus. The symptoms underwent no ame- 
lioration until his death. ^ 

This case was undoubtedly one of urinary paraplegia, 
yet its details do not at all tally with the characters which 

' ' Medico-Chirurgical Transactions,' vol. xxxix. 

' We reproduce this case here in its general details, not only because it 
exhibits this extension of the disease u^jwards in the cord, but because it 
shows the insufficiency of the theory of vaso-reflex paralysis of which it has 
been adduced as an illustration. 



PAEALTSIS OF THE LOWER EXTREMITIES. 263 

are given of urinary paraplegia as a reflex disease. Far 
from there being any correspondence between the theory 
and the facts^ there is a difference in almost every particular. 
But^ to return to the question of the limitation of paralysis 
to the lower limbs, it may be asserted that no deduction can 
be drawn from this as to the cause of the paralysis. Such 
limitation can of itself mean no more than that the lesion, 
whatever it may be, affects only or chiefly the lumbar 
segments of the cord. It is certainly no test of the nature 
of the lesion, and no peculiarity of urinary paraplegia. The 
same limitation occurs not unfrequently as the effect of 
primary myelitis, and also of that condition of the cord 
which we recognise, but which we can no further explain 
than by saying it arises from central exhaustion (asthenia). 

Such cases have already been alluded to, nor would it be 
necessary again to refer to them had not a case of this 
kind, recorded in the ' Guy^s Hospital Reports,'^ been 
quoted by Dr. Brown- Sequard in support of his theory of 
vaso-reflex paralysis, as one of urinary paraplegia. It is 
remarkable that it should have been so quoted, since there 
was no disease of the urinary organs preceding the para- 
lysis, and none until the paralysis made it necessary to use 
catheters. 

Although we should not be disposed to lay any great 
weight upon the fact, since we do not admit the validity of 
the distinctions which have been given, it may be further 
remarked that a comparison of this case with the character- 
istics of urinary paraplegia, set down according to the vaso- 
reflex theory, shows that it could not, even theoretically, 
have belonged to that class. Its symptoms contradict most 
of those ascribed to urinary paraplegia. To make this plain 
we subjoin the case itself, and a table of the symptoms in 
urinary paraplegia.^ The numbers placed between brackets 
correspond to those in the table. 

1 'Guy's Hospital Eeports/ 1858. 
- ' Lancet,' April 21st, i860. 



264 DISEASES OF THE NEEVOUS SYSTEM. 

Complete paraplegia without loss of sensation ; onset of symptoms sudden ; 
death after fourteen days, from acute peritonitis set up by inflamma- 
tion of the bladder ; no discoverable change in the structure of the 
cord beyond slight softening of the texture ; no exudation. 

Henrj P — , set. 32, clerk to a solicitor in the Citv, was admitted under my 
care into Guy's Hospital December 23rd, 1857. A tall, well-made, rather 
pallid, but otherwise healthy -looking man, suffering from entire paraplegia 
of the lower extremities and sphincters, but without affection of sensation. 
He stated that he had never previously had any serious illness, but that two 
yeai-s ago he fell whilst attempting to jump over some chairs. After a few 
days, all apparent effects of this accident passed away, and he considered 
himself in unimpaired health. In the summer of 1857 he manied, and 
gave himself to excessive indulgence in sexual intercourse ; he was other- 
wise temperate. For two or three months preceding the sudden develop- 
ment of the paraplegia, he experienced at times some difficulty in mictu- 
rition. The urethra was healthy (i). On the 9th of December there was 
numbness of the lower extremities, extending as high as the knees (2) ; but 
this was so slight as not to attract any attention at the time. On Monday, 
the 14th, he walked, as usual, from the suburbs to his business in the City. 
About the middle of the day, as he was crossing his room, his legs suddenly 
became weak, and he would have fallen had he not been supported. After 
a short time he recovered sufficiently to walk with «ome difficulty to the 
omnibus, and afterwards from the omnibus to his home. In the course of 
the afternoon he became entirely paraplegic (4, 5), the urine and faeces 
passing involuntarily fi'om him (7). There was no affection of the upper 
extremities, except slight and transient formication in the hands (3, 11). 

On admission on the 23rd there was only a trace of excito-motor activity 
in the left leg, and none in the right (6). There was no appreciable dimi- 
nution of sensation. Movements in the chest normal; pulse 120, feeble; 
pupils dilated ; surface of trunk and upper extremities warm and perspiring ; 
legs cold ; a sense of tightness around the chest, about the attachment 
of the diaphragm (10) ; bowels inactive ; urine drawn off by catheter, acid. 

The day following his admission there was noticed to be some oedema of 
the integuments in the lumbar region, especially on the right side. On the 
26th this had almost disappeared. The spine was normal ; no change in 
the paralytic symptoms (14). Occasional slight involuntary twitchings of 
the legs ; electro-contractility of the muscles good ; only the slightest trace 
of excito-motor action, and that limited to the left leg (6). The integu- 
ments over the sacrum reddened; pulse 130; skin hot and dry; urine 
ammoniacal, and containing a large quantity of very offensive mucoid pus ; 
the passage of the catheter was followed by much bleeding. During the 
night of the 28th nausea and vomiting came on, with great prostration ; 
respiration thoracic. Death from exhaustion on the morning of the 30th, 
the case having been brought to a rapid termination by the supervention of 
acute peritonitis upon inflammation of the bladder. The upper extremities 
were unaffected throughout, with the exception of the slight and transient 
formication noticed above. 



PARALYSIS OF THE LOWER EXTREMITIES. 265 



Ubinaey Paraplegia. 

1. Preceded by an afEection of the either spontaneously, or caused by 
bladder, the kidneys, or the prostate. pressure, shock, warm water, ice. 

2. Usually lower limbs alone lo. No feeling of pain or constric- 
paralysed. tion round the abdomen or the chest. 

3. No gradual extension of the 11. No formication, no pricking, 
paralysis upwards. no disagreeable sensation of cold or 

4. Usually paralysis incomplete. heat. 

5. Some muscles more paralysed 12. Anaesthesia rare. 

than others. 13. Usually obstinate gastric de- 

6. Eeflex power neither much in- rangement. 

creased nor completely lost. 14. Great changes in the degree 

7. Bladder and rectum rarely of the paralysis, corresponding to 
paralysed, or at least only slightly changes in the disease of the urinary 
paralysed. organs. 

8. Spasms in paralysed muscles 15. Cure frequently and rapidly 
extremely rare. obtained after a notable amelioratioii 

9. Very rarely pains in the spine, of the condition of the urinary organs. 

Many theories have been proposed to explain the para- 
plegia Svhich follows urinary affections. Mr. Stanley, to 
whom we are indebted for the earliest paper on the 
subject, supposed it was by the sensitive nerves transmitting 
a morbid impression to the cord, which was thence reflected 
outward upon the muscles. Dr. Graves adopted much the 
same view. He says, "If an irritation of a nerve at the 
extremities can produce disturbance and exaltation of all 
the voluntary muscular system, as in tetanus, it is not 
surprising that such a local cause, tending to depress 
instead of exalting the motility, should affect not only the 
nerves and muscles of the part upon which it is developed, 
but also those of the whole body, or chiefly distant organs.'* 

In 1856 some cases were recorded in the ' Medico- 
Chirurgical Transactions ' which proved that urinary para- 
plegia was, in some cases at least, due to inflammatory 
conditions of the cord. The table given above is formed 
upon the assumption that such cases are exceptional, and 
that urinary paraplegia is essentially different from that 
produced by myelitis. The theory of its author is that the 
paralysis arises from a contraction of the blood-vessels of the 
cord, nerves, or muscles, set up by a reflex impression 



266 DISEASES OF THE XEEVOUS SYSTEM. 

starting from the urinary organs ; tliat this reflex contraction 
of the capillaries, if of any duration, affects the nutrition of 
the textures. According to this theory, it follows that 
urinary paraplegia is due to a partial anasmia of the 
affected parts ; whilst if it be due to myelitis or its allied 
conditions, there is no doubt hypergemia. The theory is 
fairly based on the fact, established by recent experiments, 
that blood-vessels contract with energy, and, to use Dr. 
Brown-Sequard^s own words, are sometimes seized with 
a prolonged spasm, when the sympathetic which supplies 
them is directly or indirectly irritated. Thus far, therefore, 
we have a true foundation. But further than this, in the 
practical application of the theory, it fails : for it has not been 
proved to be applicable to the cases before us ; and if it had 
been so proved, the sufficiency of such vascular contraction 
to pi'oduced permanent paralytic effects might be questioned. 
That some blood-vessels stand in a nearer relation to 
nervous influence than others seems to be obvious in the 
ordinary phenomena of blushing; therefore, until we have more 
proof than at present, we have good reason for doubting if 
the blood-vessels of the cord are liable to changes in the 
same degree that we witness in experiments on the integu- 
ments of animals : — whether, in fact, the grey matter of the 
spinal cord varies in its vascularity in the same degree as 
the face of a man under emotion, or the ear of a rabbit when 
the cervical sympathetic is the subject of experiment. Dr. 
Brown- Sequard would have us answer these doubts in the 
afl&rmative. "J have seen,'' says he, '^ a contraction of 
blood-vessels in the spinal cord (in the vessels of the pia 
mater) taking place under my eyes, when a tightened 
ligature was applied on the hilus of the kidney, irritating the 
renal nerves, or when a similar operation was performed on 
the blood-vessels and nerves of the supra-renal capsules." 
He further adds, " Generally in those cases the contraction 
is much more evident on the side of the cord corresponding 
with the side of the irritated nerves : which fact is in har- 
mony with another, and not rare one, observed first by 
Comhaire (as regards the kidney), and often seen by me after 
the extirpation of one kidney or one supra-renal capsule ; that 
is, a paralysis of the corresponding lower limb. 



PAKALYSIS OF THE LOWER EXTEEMITIES. 267 

The evidence in favour of a reflex paraplegia, thus supposed 
to be obtained by experiment, vanishes under the criticism of 
further experiment. 

On laying bare the spinal cord and membranes in dogs 
and rabbits (the animals selected by Dr. Brown-Sequard), no 
other vessels are visible in the dorsal and lumbar regions 
than small veins, namely, the dorsal vein and its tributaries. 
The columns of the cord are seen white and glistening 
through the membranes. There is not any structure which 
in itself deserves the name of pia mater, such as exists over 
the convolutions of the brain. Nor are the columns of the 
cord much more vascular than tendons. There are no 
visible vessels on them, nor in the membranes, except those 
which have been mentioned. It was, therefore, a matter of 
surprise that these vessels should have been seen to con- 
tract ; and on placing a ligature on the vessels of the kidney, 
and irritating the renal nerves, certainly no visible effect 
was produced — the vessels under observation underwent no 
change. If our surprise was great at the distinctness with 
which it had been stated that the vessels of the membranes 
generally had been seen to contract when the renal nerves 
were irritated, it was greater still at the further remark, 
" that the contraction was more evident on the side of the 
cord corresponding with the side of the irritated nerves ;" for 
such vessels (venules) as are visible in the membranes of 
the cord are so distributed as to render it apparently impos- 
sible that those of one side only should be made to contract. 
They ramify without any limitation to one side of the cord 
or the other. 

Further, the occurrence of paralysis in the lower limb 
corresponding to that side on which the kidney was instated, 
or the supra-renal capsule removed, appears to have nothing 
whatever to do with reflex paralysis. Such a result does not 
follow if care be taken not to injure the lumbar or psoas 
muscles, in exposing the kidney, and putting a ligature upon 
it. We found that the animals experimented on used both 
lower extremities equally well after the extirpation of one 
kidney or the other. As they walked, we could not in the 
least conjecture from their gait which kidney had been 
removed. After this careful inquiry we must say we can 



268 DISEASES OF THE NERVOUS SYSTEM. 

discover no evidence^ from experiments on animals, for a 
theory of reflex paraplegia.^ 

Upon the terms of the theory, the animals experimented 
upon ought to have been paraplegic in one or both extre- 
mities, but this was not the case. It may be objected that it 
would be necessary to repeat such experiments indefinitely, 
before we could fairly deny that a reflex paralysis occurs. 
To which it might be justly replied, that if paralysis were 
only so rarely and exceptionally induced, and the supposed 
contraction of the blood-vessels, upon which it is said to- 
depend, were only casually to be observed, and not suscep- 
tible of demonstration, then we must hesitate before we 
embrace a theory which rests upon such uncertain and ex- 
ceptional conditions. 

We dismiss therefore as invalid, the proof from experi- 
ments on animals that urinary paraplegia arises from a reflex 
impression on the blood-vessels. 

On surveying the clinical history of the disease, it appears 
to us to accord but little with our knowledge of functional 
capillary disturbance. In most cases the paralytic affection 
shows itself only after the disease of the urinary organs has 
existed months or years; the exceptions to this rule being 
cases of acute gonorrhoea, which elsewhere have been shown 
by us to depend upon myelitis. If reflex irritation had been 
the cause of urinary paraplegia, we should have expected it 
to occur most frequently at the outset of a case, when the 
affected mucous surface was most impressionable, rather 
than after chronic disease had lasted for a long period. 

There is one case which is so often quoted in support of 
a reflex theory, that it deserves a word of mention here. It 
is recorded by Dr. Graves. 

A man, set. 38, was admitted into the Richmond Hospital in 1835. In 
the year 1826 he injured his back, and was confined to bed twelve days. In 
1830 he was exposed to cold and wet during a long and fatiguing voyage, 
and began to complain of pain in the lumbar region. At this time he had 
hajmon-hoids and irritable bladder. In 1834 he suffered much from cold, 
wet, and fatigue, during a voyage from Cadiz to Dublin, and on his arrival 
was extremely weak. After resting a fortnight, and living rather freely, he 
again went to sea ; but after nine or ten days his feebleness and the pain 

^ In these experiments I had the assistance of Dr. Pavy and Mr. Durham, 
to whom I owe my best thanks for their time and trouble. 



PARALYSIS OF THE LOWER EXTREMITIES. 269 

in the hack increased, so that he was obliged to quit his occupation. When 
admitted into the hospital his general health was much deranged. He had 
transient rigors, followed by pyrexia. There were both dysuria and incon- 
tinence, and paralysis of the lower extremities. After being treated for ten 
days by cupping, moxas, demulcents, and opiates, a very narrow stricture 
was found in the membranous portion of the urethra. A few days after 
this was dilated, the patient recovered power in his lower extremities in a 
remarkable manner. It was this sudden recovery which has been regarded 
as a proof that the paralysis depended upon some reflex impression on the 
cord from the contracted urethra. How little such an inference can be 
safely drawn will appear when we consider that the stricture was probably 
of old duration, and that the paralysis came on only after retention of urine 
when the body was greatly enfeebled, and that it was relieved so soon as the 
patient was able freely to empty the bladder. The paralysis appears to 
have been more connected, in this case, with vesical distension than with 
the urethral irritation ; for certainly this latter existed for a long time 
before the paralysis. If we admitted the principle sought to be established 
by those who quote this case, we should certainly have expected to meet 
with paraplegia from such a cause much more frequently. Urethral stric- 
ture is so. common, that we ought scarcely to need the evidence of a rare 
case, occurring once in many years, to elucidate its operation as a cause of 
reflex paralysis, if it had any true title to be so regarded. 

The sex of the patients most liable to this disease is not 
less conclusive against its depending upon mere reflex irri- 
tation. Calculus, cystitis, and pyelitis are not uufrequent in 
women, and yet urinary paraplegia is in them extremely rare. 
The cause of this immunity is not to be found in their having 
a less susceptible nervous system, which the reflex theory 
would seem to require, but in the less complicated anatomical 
conditions of their urinary organs, and consequently a less 
need of mechanical interference, and a less liability to the 
extension of inflammation to the pelvic structures and to 
the cord. 

We have already noticed that children are not commonly 
the subjects of urinary paraplegia ; yet at no age is the nervous 
system more susceptible. 

If we regard the nature of the urinary disease which most 
commonly leads to paraplegia, we shall find that it is an 
inflammation, either in the prostate, bladder, or kidneys ; 
and we shall also find, as above stated, that it is only after 
chronic inflammation has lasted a long time that the para- 
plegic weakness supervenes. It is in just those cases 
where there is most irritation, and but little inflammation, 



270 DISEASES OF THE NERVOUS SYSTEM. 

that paraplegia does not occur. Uric acid and oxalate of 
lime calculi may cause haematuria and any amount of irri- 
tation, but unless swppurative inflammation sets in, para- 
plegia is not produced. A review of all the recorded cases 
of urinary paraplegia will show that it is the inflammatory 
condition of the urinary organs which leads to paralysis, and 
not one of irritation. 

One conclusion from all these facts is, that urinary para- 
plegia arises from an altered nutrition of the cord, due to 
extension of disease through continuous structures to the cord 
itself. To this it has been objected that we ought in such 
cases to find traces of myelitis after death ; and that if it were 
a myelitis, we could not expect any improvement in a case 
of urinary paraplegia — that the disease, having once begun, 
would more or less rapidly advance. 

The statement that the cord has been found healthy in 
these cases has, in fact, no value. We have long learned 
how fallacious are the ordinai'y examinations of the cord. It 
is a structure which may be extensively disorganised by 
inflammatory action, and yet have a normal appearance to 
the naked eye. It has been said that I have myself supplied 
proof that urinary paraplegia may occur without any change 
in the cord. The case referred to, however, was not one of 
urinary paraplegia, as we have seen, but one of asthenia. 

How difficult it is to ascertain whether the cord be healthy 
or not, will be admitted by all who have devoted time to 
investigating its morbid conditions ; and they will be but little 
disposed to accept any positive statement respecting it, which 
is not based upon an expert examination by the microscope. 

A young married woman was, a few months ago, admitted under my 
care with entire paralysis of the arms, the legs not being at this time so 
much affected, though weak. She died from asphyxia, from paralysis of 
the intercostals. The limitation of the disease to the cervical segments 
during the early part of the case was most striking. After death the 
unassisted eye could discover nothing wrong, and, in fact, it was only after 
a careful preparation of the cord by hardening and thin sections, aided by a 
gentle daylight, that the degeneration could be made out. I laid the slides 
on one side at first in despair. 

The second objection, that if urinary paraplegia were due 
to any form of myelitis we could not anticipate improvement, 
is answered by our daily clinical experience. In the re- 



PARALYSIS OF THE LOWER EXTREMITIES. 271 

covery from paralysis caused by antero-posterior curvature 
of the spine, and after injuries to the back, we have evidence 
that the cord, like other structures, is capable of repair. 
This is further confirmed by experiments on animals. 

If we inquire into the effects of remedies in urinary para- 
plegia, it will appear that it exhibits no such sudden and 
extreme changes as indicate a mere vascular disturbance as 
its cause. In a large number of cases (excepting such as 
are not paraplegic, but where there is only debility) the 
disease slowly progresses. Where improvement shows itself, 
it is generally the effect of such means as are useful in 
chronic inflammation of an atonic character elsewhere ; 
namely, careful regimen, tonics, opiates, warm baths, and 
thermal springs. The subjects of urinary paraplegia are 
generally enfeebled. It is often the result of sexual intem- 
perance and its concomitants. They who adopt the theory, that 
the disease is for the most part only a vaso-reflex disturbance, 
advise on such grounds the frequent use of catheters. This 
course is not unattended with danger. There is no part of 
the treatment which calls for more discrimination. The 
diseased textures and veins about the neck of the bladder 
are so prone to suppurate, that the catheter is often a fatal 
weapon. The few scattered instances, such as that recorded 
by Dr. Graves, where immediate good elfects have followed, 
have had undue influence towards promoting mechanical 
interference. Carefully considered, they do not warrant the 
inference drawn from them. If the urinary passages are so 
contracted that the bladder cannot empty itself, the catheter 
is obviously required, but it cannot be simply prescribed on 
other grounds. The rule for its use is the same as in the 
treatment of the aural passages when the middle ear is 
diseased. If there be a free exit for the secretions, the less 
mechanical interference the better. As meddlesome mid- 
wifery is bad, so is the meddlesome employment of the 
catheter in urinary paraplegia. Cases might be quoted 
where a fatal issue has been induced by this meddlesome 
interference with a diseased bladder, under the hope of 
removing some hypothetical cause of reflex irritation. 

Since urinary paraplegia has lately been used as synony- 
mous with reflex paralysis from disease of the urinary organs, 



272 DISEASES OF THE NERVOUS SYSTEM. 

it is worth inquiry what is meant by " reflex paralysis." 
The term has been variously used. Dr. Brown- Sequard 
employs it, as we have done, to express the result of a reflex 
contraction of the blood-vessels upon the nuti-ition of the 
several structures concerned in muscular action. According 
to others, it signifies a loss of excito-motor activity from an 
insusceptibility of the incident surface to impressions ; as, 
for example, when dysphagia follows anaesthesia of the 
fauces. This is, in some sense, a reflex paralysis, or rather 
a paralysis of the reflex actions. More commonly the term 
is used to express the progress or transference of a morbid 
action from the periphery to the nervous centres, and thence 
on to the motor nerves and muscles by a continuous change 
in the nerve-trunks or other intervening textures. This is 
''creeping palsy," or, as it is sometimes called, ''peripheral 
palsy." As illustrations of it, we see injury to a finger 
involve the whole hand, or even the whole arm in paralysis ; 
or injuiy to an extremity on one side affect that of the 
opposite side. The records of medicine contain many such 
examples. The steps of the process are not always the 
same. Sometimes the lesion seems to spread along the 
nerve-trunks by chronic inflammation or atrophy, at other 
times the blood-vessels (arteries) become slowly obliterated. 

A young lady wounded her finger. The arm became generally painful 
and cold. When brought for examination the whole arm was powerless 
and wasted. The radial pulse was not to be felt ; and on tracing the coui-se 
of the artery up to the axilla it was found painful and resisting, but 
without pulsation. By keeping the arm warm, and by time and rest, the 
power to some extent returned with returning circulation ; but, though 
three years have passed, it has never recovered its full size and strength. 

The observations of Waller on the degeneration of nerve- 
tubules after injury to the nerve-trunks, and those of Turck 
into the progressive degeneration of the tubules in the 
nervous centres, when a lesion has begun at any part, 
promise to throw some light upon what is yet obscure in 
these creeping palsies. We refer to them only to remark 
they are not due to reflex action or reflex paralysis ; and it 
is not unnecessary to make this remark, seeing how often 
the error is committed of assigning every form of palsy 
which follows a peripheral injury to a reflex effect. 



PARALYSIS OF THE LOWER EXTREMITIES. 273 

In confirmation of the views here expressed, we quote the 
opinion of Eomberg. He says, " The progress of reflex 
immobility into paralysis is not as yet proved either by ex- 
periment or clinical observation. My former admission of 
reflex paralysis, against which on many sides doubt and 
opposition have arisen, has not a secure basis. Since 
Stanley published the first cases to prove the dependence of 
paraplegia upon disease of the kidneys, the number of these 
observations has multiplied, especially by French physicians, 
but without a corresponding criticism. Not to mention the 
unsatisfactory description for the most part given of the 
paralysis itself ; the want of evidence afforded by electricity ; 
and the vague indication, noted in many of the cases, of 
weakness of the extremities; it has been inferred from the 
apparent integrity of the cord on a post-mortem examination 
that the paralysis was due to degeneration of the kidneys. 
It is, however, of little value to assert integrity without 
microscopic examination (which is not named in any one of 
the cases), or without having proved that in neither of 
the columns of the cord nor in any other part was there 
degeneration."-^ 

To this it may be added, in conclusion, that as yet no 
case of urinary paraplegia has been fully examined, post 
mortem, without finding such degeneration. 

'- ' Nerven Ki-ankheiten des Menscheu. Dritte veranderte Auflage,' 1857. 



18 



LESION OF THE NEEVES IN THE NECK 



AND OV THE 



CERYICAL SEGMENTS OF THE CORD AFTER 
"FAUCIAL DIPHTHERIA."^ 



During the last two years it has occurred to rue to see 
diphtheria in a severe form iu several instances. There have 
been two varieties of the malady. In one, the disease began 
in the tonsils or soft palate, and was characterised by an 
exudation of brownish fibrin upon these parts, often to a 
very remarkable extent. In some cases, as the disease pi'O- 
gressed, the glands and cellular tissue of the neck became 
swollen and hard, as in phlegmonous erysipelas ; the skin 
over the affected parts became pnrpurous, and a bloody ichor 
was discharged from the nostrils. This variety of the dis- 
ease might be designated, for the sake of distinction, 
'' faucial diphtheria" to distinguish it from the second form, 
in which the exudation is on the sides or general surface of 
the tongue, or the mucous membrane of the cheeks and lips, 
and, in common with these, over the tonsils and soft palate. 
In this second variety, death when it occurs, arises as far 
as I have seen, from a cause different from that in the first ; 
namely, by extension of the disease over the respiratory or 
digestive mucous surfaces, occasioning symptoms of croup 
and gastro-enteritis : whilst, in the first or faucial variety, 
death results rather from asthenia, apparently induced by 
direct injury to the pneumogastrics and sympathetic system 
of nerves, through inflammation of the areolar tissue in the 

* Reprinted from the 'Lancet,' July 3rd, 1858. 



DIPHTHERITIC PARALYSIS. 275 

neck. It is not, however, my object to discuss these points 
in the history of the disease, but to call attention to the 
important complication which occurs in the convalescence 
from the faucial variety. The symptoms appear to arise 
from a lesion of the trunks of the nerves about the throat, 
or from a further extension of it to the cervical portion of 
the cord. 

About a fortnight ago I was called to see a boy, of whom I received the 
following history: — ^t. ii. Had had an affection of the throat, from 
which he convalesced, and was sent into the country for change of air. 
About five weeks from the time of his being taken ill it was noticed that he 
did not carry the head erect — it dropped to one side or the other. There was 
occasional difficulty in deglutition, loss of voice and attacks of dyspncea 
threatening asphyxia. In a day or two from the beginning of these sym- 
ptoms the breathing became entirely thoracic. The diaphragm was un- 
moved in inspiration and depressed in expiration, indicating a loss of power 
in the j^hrenic nerves. Deglutition was next to impossible. The child 
could utter no sound. There were fearful attacks of strangulation when 
the head was moved in particular positions, and even when the breathing 
was at the best there was blueness of the lips and tracheal rales. The 
intelligence remained unaffected. The legs could be moved only feebly ; 
the movement of the arms was not impaired ; the muscles of the neck were 
wasted and flaccid ; there was no swelling of the fauces ; over the trans- 
verse processes of the cervical vertebrae, on the right side, there was tender- 
ness, and the adjacent deep-seated absorbent glands were slightly enlarged. 
No febrile excitement. Pulse feeble, 90. A paroxysm of suffocation 
suddenly ended the case a few hours after my visit. No post-mortem 
examination could be obtained. 

A few days after I had seen this case a similar one was 
brought to me by my friend Dr. Kiugsford, of Clapton. 
The previous history was all but identical with that just 
given, except that the faucial affection had been apparently 
more severe. 

A child, set. 3 years, had had a severe attack of diphtheria about the fauces, 
and was recovering when, at the end of a month, it was noticed to carry its 
head stiffly ; the gait was unsteady, the right leg being weaker than the 
left. Voice husky and indistinct, and deglutition sometimes difficult. The 
sphincters continued to act well. There were no remains of the disease on 
the mucous membrane of the fauces. The throat had healed well, but still 
the deep-seated absorbent glands on the right side of the neck could be felt 
enlarged. The movements of the chest and upper extremities were normal. 

The extension of inflammation from the contents of the 
pelvis to the membranes and lumbar segments of the cord 



276 DISEASES OF THE NERVOUS SYSTEM. 

has been elucidated by some cases of paraplegia recorded in 
the ^ Medico-Chirurgical Transactions' for 1856. These 
cases following diphtheria appear to belong to the same 
pathological series, the cervical portion of the cord being af- 
fected from disease in the fauces in a similar way to the 
lumbar segments in vesical or other pelvic affections. They 
are so far imperfect that the first was not examined post 
mortem, and the second is still under treatment, but they 
appear to be sufficiently distinct as illustrations. I should 
not have ventured to record them, however, without further 
confirmation, but that it seemed desirable not to delay an 
inquiry where, it is to be hoped, the opportunity for further 
observation will soon have passed away with this new or 
newly revived pestilence. 



CASE 

Of 

PROGRESSIVE ATROPHY OF THE MUSCLES 
OF THE HANDS : 

ENLARGEMENT OF THE VENTRICLE OF THE CORD IN 

THE CERVICAL REGION, WITH ATROPHY OF 

THE GREY MATTER (HYDROMYELUS) / 



The following case is given as a contribution to the patho- 
logy of " progressive muscular atrophy.'^ 

Three classes of cases are as yet confused together under 
this term and its synonym, " wasting palsy/' 

Progressive, or perhaps better, " excessive " muscular 
atrophy, may arise from primary lesion of the muscular 
elements — or from lesion of the trunks or branches of the 
nerves — or from morbid changes in the grey matter of the 
cord. It is the difficulty of distinguishing the primary seat of 
disease in each of these classes of cases, which has led to ex- 
clusive, and therefore erroneous views of their pathology, one 
observer maintaining that progressive muscular atrophy is 
always a peripheral affection, whilst another asserts that it 
has constantly a centric or spinal origin. 

Besides the forms here enumerated, there is a fourth class, 
in which muscular nutrition fails from a morbid diathesis 
allied to rickets. It has nothing in common with the patho- 
logy of the former cases but the want of muscular power. 
Dr. Meryon's ^ are good examples. I have seen the disease 

^ Reprinted from the ' Guy's Hospital Reports,' 1862, p. 244. 
^ ' Medico-Chirurgical Transactions,' vol. xxxv, p. 73. 



278 DISEASES OF THE NERVOUS SYSTEM. 

in two girls of one family. It is a malady beginning in, and 
limited to childhood, and peculiar to it. The muscles are not 
diminished in bulk at the commencement of the disease, nor 
is there necessarily any paralysis during the whole course of 
the case, but only a lentor and feebleness of movement. 
This cursory mention of such cases is sufficient to show with 
what little practical value they can be included in the first 
enumeration. No doubt much of the obscurity which at 
present besets this subject is favoured by the assumption, 
that where disease was not discovered in the cord, it did not 
exist ; happily, however, positive assertions from negative 
evidence are at this day considered of less weight. We 
cannot peruse recorded cases of progressive muscular atrophy, 
without feeling how unsatisfactory, in most of them, is the 
post-mortem examination of the cord, and must hesitate to 
accept the conclusion that it was free from lesion, because 
none was discovered. Dr. Beale's ' Archives' (No. 9) contain 
an almost critical case in illustration of these remarks, and 
certainly, but for the rai-e skill of Mr. Lockhart Clarke, it 
might have been recorded as one of muscular atrophy, the 
cord being healthy. Thanks, however, to the means we 
possess of investigating ultimate structure, Mr. Clarke was 
able to show that there were certain areas of the grey matter 
which had undergone marked change of a morbid character, 
although the cord had an entirely healthy appearance. 
During the life of the patient referred to, there was a differ- 
ence of opinion as to the primary seat of the malady, and 
but for such an exhaustive examination as it received after 
death, instead of its being a contribution to our knowledge, 
the record of the case would have served only to give strength 
to false assumptions, and fortify us in the error of assuming 
that all is sound where imperfect examination detects no 
weakness. 

The following case, on its entrance into the hospital, gave 
rise to the same question — whether the muscular atrophy had 
a peripheral or central cause. The patient was a journey- 
man tailor, working hard at his business in London, and, 
therefore, of necessity using the muscles of his hands in an 
extreme degree. Here, therefore, Avas a possible, and not an 
improbable cause of a primary affection of the muscles them- 



PROGRESSIVE ATROPHY OF THE MUSCLES OF THE HANDS. 279 

selves, but, as was remarked in a clinical lecture given on 
the case, it was to be remembered that the will does not 
directly act upon the muscles in voluntary movement, but upon 
the grey matter of the cord to which the nervous filaments 
are connected, and therefoi*e, that it is as reasonable to 
infer a lesion of the grey matter from overwork, as of the 
muscles. 

The first symptom, in this case, was inability to extend the 
little and ring fingers of the right hand, with a sense of 
coldness and numbness in the part. This was the only 
complaint for eleven months, and no doubt, if the patient 
had been seen during that time, it might have been thought 
more probable by some that the disease lay in the muscular 
tissue than in the centre of the cord. It was not until after 
eleven months that the adjoining middle finger began to fail 
in a similar way. A perusal of the case will show, that 
the centre of the cord had by this time undergone exten- 
sive changes, yet it was not until the left hand became 
affected, that the central character of the lesion began to 
appear, and even then it might have been contended, that 
the symmetry of the muscular affection was owing to the 
same conditions of over-wear in both hands. Had it not 
been for typhus fever, which then prevailed with unusual 
virulence in the hospital, we should not have known how 
great morbid changes the central grey matter of the cord 
may undergo, with but slight and limited and only slowly 
progressive peripheral effects. The lesion discovered after 
death was evidently in no way connected with the attack of 
fever, nor in any way affected by it. The tissues at fault 
showed no traces of recent activity about them. This case 
is therefore another instance of atrophy progressing from 
muscle to muscle in the slowest way, and unattended by any 
of the common proofs of central disease, though depending 
upon it. 

It also suggests some doubt respecting the validity of the 
present theories of the function of the grey matter of the 
cord. A glance at Plate IV (p. 282) of a transverse sec- 
tion of the cord in this case, will show how large a part of 
the grey matter may be slowly removed, without affecting 
sensation to any corresponding extent, and without disturbing 



280 DISEASES OF THE NERVOUS SYSTEM. 

the general functions of the cord^ or the influence of the 
brain upon the parts below. 

Although there were no other remains of the grey matter 
in certain parts of the cervical region except the anterior 
cornua, the patient was still able to walk perfectly well, and 
to move the arms freely in all directions, and the sphincters 
were good, nor was there any affection of sensation in any 
part, except a feeling of numbness in the right hand. 

What the nature of the change in the cord was, may be a 
matter for speculation. So far as it affected the grey 
matter, it seemed to be no more than atrophy from disten- 
sion of the ventricle of the cord, by an accumulation of fluid 
in it — a chronic cervical hydromyelus, comparable to a 
chronic hydrocephalus. 

It is noticeable that normal epithelium still lined this ex- 
tremely dilated ventricle. 

The appearance of a distinct membrane to the cavity was 
produced by condensation of the normal textures pressed 
outwards, and not by any new plasma. 

The extent to which the disease reached in a longitudinal 
direction, is shown in the woodcut, the dotted outline in the 
middle of the cord indicating the extent and form of the 
cavity in the interior. 

The greatest diameter of the cavity was opposite the 
origin of the seventh or last cervical nerve, and hence the 
peripheral effects were chiefly marked in the branches of the 
ulnar nerve, which here has its principal origin. 

The form of the cavity, on a transverse section, is shown 
in the plate. It will be observed that it was not a simple 
circular dilatation, but corresponded to the general disposi- 
tion of the grey matter and its cornua. 



G. B — , set. 44, a ioui-nejman tailor, of sober habits, was admitted into 
the clinical ward, FebrvTary 5th, 1862. States that he has always been 
healthy and strong. Never had any injury to his back. Thirteen months 
ago, when working in London, the fourth and little finger of the right hand 
became weak and flexed, without any assignable cause. The hand was cold, 
and there was a feeling of numbness in the fingers, but no pain. This gave 
rise to a good deal of inconvenience, but he was able to continue working at 
his trade. Two months ago the middle finger of the same hand became 
suddenly affected, and three weeks ago the three inner fingers of the left 



PROGEESSIVE ATEOPHY OF THE MUSCLES OF THE HANDS. 281 



hand became weak and flexed in the same way, but without any numbness. 
The hands gradually wasted. The arms are not affected. Seven weeks ago 
he had pains through his chest, and a feeling of tightness across the upper 
part. He is pale, complains only of wasting 
and weakness of the hands ; has no pain in 
them, but the right is cold, with a feeling of 
numbness. The left hand is not so cold, and 
the Sensation in it is perfect. He can move 
both thumbs and index fingers freely ; he can 
also extend 'the first phalanges of the other 
fingers of both hands, but not in the least 
degree the second and third phalanges, which 
are gently flexed towards the palm. The 
interosseous spaces on the backs of the hands 
are sunken from the wasting of the muscles. 
The palms of the hands are hollow, and the 
flexor tendons veiy prominent. The thenar 
eminences are wasted, and the hypothenar 
almost entirely gone, particularly on the right 
side. The motion of the wrist-joints is un- 
affected. He can move the arms freely in all 
directions. Can walk perfectly well. '^-^- ' ■' ""^ ^^ ' 

At the upper pai't of the dorsal region there 
is slight flattening of the natural curve of the 
spine, from the long muscles of the back 
being at this part wasted. Pressure on the 
fourth dorsal spinous process causes a sharp 
pricking pain, as of a knife running into the 
part, but when the part is not touched he has 
no pain. No pain on pressing the other 
spinous jn-ocesses ; no affection of sensation in 
any part except the feeling of numbness in 
the right hand ; sphincters good ; urine nor- 
mal ; appetite and digestion good. He was 
put upon a full diet, and the wasted muscles 
were daily galvanised by an intermittent cur- 
rent. A fortnight after admission he had 
gained power in the hands. He said he felt /' 

them stronger and more pliable after each 
application of the galvanism. It was noted 
that, with a moderate current, the contrac- 
tility of the muscles of both hands was good, 
but more particularly in the short muscles of 
the thumb, which were least wasted. Sensi- 
bility not so acute in the right hand as in the Diagram of spinal cord show- 
left, but no marked anesthesia of either. Both ii^o enlargement of ventricle, 
hands were rather cold. A few days after this report the patient sickened 
with typhus fever, and died on the 8th of March 



6 



282 DISEASES OP THE NERVOUS SYSTEM. 

A post-mortem examination was not permitted at the hospital, and it was 
only after much difficulty that the cord could he obtained. The bones and 
ligaments of the spine were healthy ; the membranes of the cord healthy ; 
the exterior of the cord presented nothing abnormal, except that the cervical 
enlargement appeared broader and somewhat flattened. On making trans- 
verse sections the white columns had their normal consistence and texture, 
but the centre of the cord had a large cavity, beginning at the fifth cervical, 
enlarging downwards to the seventh, and from thence tapering as in the 
accompanying woodcut. The appearance of the cord on a transverse section 
at the origin of the seventh cervical nerve is shown in the annexed plate. 
It will be seen that the only remains of the grey matter are at the anterior 
part of the cavity behind the anterior columns. Here the caudate vesicles 
had their normal size and structure ; the pigment, nucleus, and nucleolus 
being well marked, and the tubular structure unaltered. The cavity in the 
cord was bounded by a layer of condensed grey substance, which could be 
separated as a distinct membrane. On its interior surface, forming the 
lining of the cavity, were a number of delicate, elongated, nuclear bodies, 
apparently epithelium. One or two granule-cells were found scattered 
amongst the white columns, but no further traces of any active tissue 
change. The roots of the nerves appeared normal, and contained healthy 
tubules. The character of the fluid filling the cavity could not be ascer- 
tained, as it escaped in the removal of the cord from the spinal canal. 



PLATE IV. 

Transvei"se section of the spinal cord, at the origin of the seventh cervical 
nerve (Case of G. B — , p. 280), showing enlargement of ventricle. 

The centre of the cord was hollowed out into an irregular square cavity or 
ventricle, with cornua corresponding to the general disposition of the grey 
matter. 

This cavity was limited by condensed grey matter, and lined by an imper- 
fect epithelium. 

Towards the posterior columns, and at the origin of the posterior roots, it 
will be seen that little, if any, gi-ey matter was left. 

Anteriorly the grey matter is spread out, and in it, by the microscope, the 
caudate vesicles could be seen, having their normal structure. 

The white columns are shown in the drawing a little disintegi'ated, and 
irregularly spread out, owing to the thinness of the section. 

They had quite a normal structure, except that after repeated examina- 
tion, one or two granule-cells were detected in them. 

The membranes surrounding the cord, shown in outline in the plate, were 
healthy. 



PLATE IV. 




Case G. B — , p. 280. 



yidlard and Son, Imp. 



(c) DISEASES IN WHICH SYMPTOMS REFER- 
ABLE TO THE NERVOUS SYSTEM 
ARE PREDOMINANT. 



HYPOCHONDEIASIS. 



Definition. — A disease of the nervous system, of un- 
known and possibly varying seat. It is markedly hereditary, 
being one of the transformed neuroses which descend from 
a parent stock strongly tainted with insanity. Its principal 
feature is mental depression, occurring without apparently 
adequate cause ; and taking the shape, either from the first, 
or very soon, of a conviction in the patient's mind that he 
is the victim of serious bodily disease. The sufferer's belief 
in this disease is so firm, that he describes minutely the 
symptoms, which as he fancies, indicate its existence. But 
he may place the imaginary malady in almost any organ of 
the body, and he usually describes some symptoms which 
are anomalous, or even incredible. Finally, hypochondriasis 
may be evoked by a real organic disease acting as an irritant 
to an hereditarily predisposed nervous system ; in this case, 
the anomalous nervous symptoms may mask, and even con- 
ceal, the occurrence of serious changes in some viscus. 

Nomenclature. — The same name has been applied to the 
disease since the days of Hippocrates : it has always been 
known as " Hypochondriasis," or the "■ hypochondriac dis- 
order," and sometimes as the "vapours," or the "spleen ;" 
but these two last synonyms are, in fact, mere explanations 
of the ancient hypothesis which was expressed in the word 
Hypochondriasis. This hypothesis it is really important to 
say a few words about, since the vulgar conception of the 

1 By William Withey Gull, M.D., and Edmund Anstey, M.D. Eeprinted 
by permission of Messrs. Macmillan and Co. from Reynolds' ' System of 
Medicine,' vol. ii, 1868, p. 293. 



288 DISEASES OF THE NERVOUS SYSTEM. 

disease still, though unconsciously, clierishes it ; although 
our improved knowledge of the relation of the nervous 
system to the organism generally has now made it an ana- 
chronism. 

The words viro-j^ov^piaKov TrdOog, applied by Hippocrates 
and Galen to the disease, imply a belief that the viscera 
behind the xiphoid cartilage, and below the diaphragm,^ were 
its seats ; and Galen very distinctly says that hlach hile is 
its cause. It is worth while to recall for a moment the 
physiological ideas which Galen, with great ingenuity, had 
compounded from the speculations of Plato on the one hand, 
and Hippocrates on the other. According to Galen, the 
functions of the human body were maintained by three 
Tn'EWjitara (whence, remotely, our " vapours "). The lowest 
of these was the Trvivfxa (pvaiKov, and developed the natural 
force in the liver ; the second was the Trvevina ^wrtKoV, which 
elaborated the vital force in the heart ; and the third and 
highest was the Trvev/na •^v-^ikoi', which developed animal 
or soul force in the brain.^ Anyone who has been curious 
enough to investigate these questions will see at once that 
the lowest or " natural " force of Galen is the counterpart 
of that lowest kind of mortal soul which Plato^ represented 
as residing in the abdominal organs, and chiefly in the liver, 
and as having to do with the baser animal passions and the 
supply of the needs of vegetative life. The ancient tendency 
to view every source of functional activity as an entity — 
almost a personality — made it quite consistent for the long 
succession of Galenist physicians to endow the liver-force 
with a quasi-consciousness and perception, and even with 
voluntary activity, though of a low kind ; and, on the other 
hand, the Paracelsian and Helmontian doctrine of the 
Archseus rather added to than changed anything in the 
extraordinary power over the general organism which was 
attributed to the abdominal organs. Then the absence of 

' The viscera of the hypochondria, to which the ancients attached such 
importance, seem to have been especially the liver, the pyloric part of the 
stomach, the omentum, the mesentery, and the spleen. The stomach con- 
sidered as a whole they regarded rather lightly. 

- ' De Loc. Affect.,' v. ' De Usu Part.,' v. ' De Usu Resp.,' 163, 164. 

^ ' Timseus,' ed. Stallbaum, §§ 69, 70. 



HYPOCHONDRIASIS. 289 

any accurate knowledge of the functions of a central nervous 
system, the recipient of sensory impressions, and the origi- 
nator of motor acts, induced men to localise in the various 
organs tlie source of the functional disturbances which 
appeared to be manifested therein. The vagaries of hypo- 
chondriacal sensation were therefore, in the ancient view, 
the perturbations of the natural force generated in the liver, 
spleen, and pyloric part of the stomach. It is to be 
remarked, moreover, that hypochondriasis was very generally 
confounded with hysteria (to which it doubtless has a rela- 
tion) quite down to the present century. There is nothing 
surprising in this. The flatulence which is frequently a 
striking symptom both in hysteria and hypochondriasis was, 
for the ancients, a commotion of the natural spirits which 
resided in the abdomen. 

Of the long list of authors who have treated of hypochon- 
driasis, since the days of Gralen, there is scarcely one who 
viewed the disease in any essentially different light from 
that in which Galen regarded it, until we come to Thomas 
Willis, the great investigator of the nervous system. It 
is easy to see what were the common ideas on the subject 
at the time by consulting that curious book, Burton's 
' Anatomy of Melancholy,' which was published a few years 
after Willis's death, and which represented the knowledge 
which a learned and clever layman might pick up without 
knowing, or without demeaning himself to notice, the 
writings of a contemporary countryman. Burton says that 
the general view of authors represents the hypochondriac or 
windy melancholy as arising " from the bowels, liver, spleen, 
or membrane called mesenterium," and quotes Laurentius as 
dividing it into three kinds, the hepatic, the splenetic, and 
the mesaraick. 

Willis,^ on the other hand, placed hypochondriasis amongst 
the diseases proper to the diathesis spasmodica ; he made it 
an affection of the nervous system, but so far conformed to 
the old ideas as to attribute its ultimate causation to im- 

^ T. Willis, ' Opera Omnia,' 4to, Genevse, 1676. The whole treatise, ' De 
Morbis Convulsivis,' and that on ' Hysteria and Hypochondriasis ' (in reply 
to the strictures of Nat. Highmore), are astonishing efforts of genius, and 
will well repay perusal in the present day. 

19 



290 DISEASES OF THE NERVOUS SYSTEM. 

purity of tlie splenic blood. In the next century, Flemying^ 
ventured a more distinct opinion that the brain was the part 
primarily affected, and Cullen^ and Robert Whytt^ (especially 
the former) placed great stress on the share which the 
nervous system has in the production of the disease. The 
next prominent step was taken by Georget* (1819), who pro- 
tested against the view (at that time still commonly 
prevailing) of the abdominal oi'igin of hypochondriasis, and 
the practice of powerful purgation, &c., which was based 
upon it. But the most complete and effective attack on the 
old view was made by J. Falret,^ in 1822. This author dwelt 
strongly on the hereditary character of the disease, and the 
great frequency with which it is immediately excited by 
stress of intellectual labour, or by moral and emotional 
causes. The view of Falret was perhaps carried to excess 
in limiting the primary seat of the disease so strictly to the 
brain ; but it has prevailed, and hypochondriasis is now 
commonly placed among the varieties of insanity. Griesinger, 
for instance, in his admirable treatise on mental diseases,® 
makes hypochondriasis a variety of melancholia, which is 
his first class of " mental diseases characterised by 
depression ; " and Leidesdorf ^ adopts the same view. It 
will be seen that the view which we hold differs in some 
degree from this ; but there can no longer be any doubt 
that the true seat of the disease is in the nervous centres. 

History. — The history of a hypochondriac patient is that 
of his nervous system under the two aspects of its con- 
genital form and the influences — of nutrition, education, and 
emotion — to which it has been subjected. So far it is not 
different from the story of the sufferer from any other form 
of nervous disease. But hypochondriasis is distinguished 
by this, — that a more important part is played by the 

1 ' Neuropathia, sive de Morb. Hyperchond. et Hyster,' Ebor., 1744. 
" ' Clinical Lectures,' London, 1777, pp. 39—57- 

' ' Observations on the Causes, Nature, and Cure of the Disorders called 
Nervous, Hypochondriacal, &c.,' London, 1777. 

* ' De la Phys. du Syst. Nerv.,' Paris, 1819. 

* ' De I'Hypochondrie et du Suicide,' Paris, 1822. 

* ' Die Path, und Therap. der Psych. Krankheiten,' 2nd edit., Stuttgart, 
1861. 

7 ' Path und Therap. der Psych. Krankheiten,' Erlangen, i860. 



HYPOCHONDRIASIS. 291 

congenital disposition of the nervous system, and a less 
important part by the physiological and spiritual influences 
which have been brought to bear on it, than is the case 
with the majority of nervous diseases. It comes nearest, in 
this respect, to insanity on the one hand, and to epilepsy 
and neuralgia on the other. It is the almost inevitahle 
inheritance of a certain percentage of the descendants of 
any individual who may be very strongly tainted with insanity. 
On this subject we shall say no more till we can discuss 
more fully the etiology of this singular disease. 

Symptoms. — This phrase is pre-eminently appropriate to 
the phenomena of hypochondriasis. Of physical signs we 
have almost none to guide us ; and this is in perfect agree- 
ment with the position which this disorder holds in the 
category of diseases generally. All is in the region of 
symptoms. For the most part, too, the symptoms are sub- 
jective only ; still there are features which the experienced 
physician can detect, and which can hardly be simulated by 
a malingerer. 

The most important external feature of hypochondriasis is 
this, — that without any sufficient reason for such conduct, 
and without any signs of intellectual insanity, the patient is 
observed to concentrate his attention on some particular 
organ of his body, and to fancy that it is seriously diseased. 
This concentration of attention is often preceded and 
accompanied by notable depression or variability of his 
spirits, with a tendency, on the whole, to depression ; this 
is not always the case, however, for there is sometimes no 
antecedent symptom connected with the general mental 
state. In many instances the patient^s first sufferings take 
the form of what he himself considers dyspepsia, but which 
is in fact little more than flatulence, from the formation of 
large collections of gas in the stomach and bowels. Along 
with this flatulence there are sometimes appearances which 
give a superficial colour to the idea of a primary stomach 
derangement ; the tongue, for instance, is often pasty and 
coated, and there may be foul breath ; the appetite is not 
unfrequently ravenous, capricious, or well-nigh lost ; there 
is generally obstinate constipation ; in rare cases there are 
even attacks of vomiting. 



292 DISEASES OF THE NERVOUS SYSTEM. 

More commonly there is an antecedent mental change, the 
character of which it is at first difiicult to seize, and which 
forms one of the grounds for the modern practice of 
including hypochondriasis in the varieties of actual insanity. 
Before any local symptoms have declared themselves, the 
patient has already become changed in his disposition ; in 
most cases, perhaps, the change is simply in the direction of 
despondency or vague alarm, for which he can give no 
reason. It is remarked by alienists that the mental con- 
dition, even thus early, is characterised above all things by 
an expansion of the self-feeling, a pre-occupation of the 
patient with his own condition, to the exclusion of other 
interests and affections. This is true, but it appears to us 
that the self-concentration is more like that of a person in 
the preliminary stage of an acute inflammation or fever, the 
nature of which is not yet declared, than the egotistic 
alteration of character which seems to lie at the basis of 
insanity, and which probably depends directly upon minute 
changes taking place in the cortical substance of the brain. 
It is a real bodily sensation (though at first indescribable), 
which enchains the sufferer's attention ; and before long 
this vague feeling is exchanged for a positive localised sense 
of uneasiness or actual pain. 

Sometimes the early mental state is one not merely or 
chiefly of despondency, but characterised by suspiciousness 
and irritability of temper, with quick changes from high 
spirits and loquacity to moody silence. In any case, after a 
time, the patient not only exhibits in his aspect and conduct 
the general uneasiness from which he suffers, but begins to 
complain of definite subjective symptoms. Probably the 
most common of these is pain of a gnawing or bui'ning 
character, or else a sense of great though vague uneasiness 
at the pit of the stomach. But in fact any part of the 
peripheral distribution of the sensory nerves may be the 
apparent seat of painful sensation, and besides this there is 
very often a general heightened sensibility of the skin. 
Both the active pain and the heightened sensibility of (un- 
complicated) hypochondriasis are subjective, and resemble 
the similar phenomena which are so common in hysterical 
women, in vanishing when the patient's attention is power- 



HYPOCHONDRIASIS. 293 

fully diverted from them. The painful sensations of which 
hypochondriacs complain are very acute ; and their severity 
concentrates the attention of the sufferer exclusively upon 
them, increasing the apparent egotism of his disposition. 
But it may here be remarked that the heightened self- 
feeling of hypochondriasis does not partake of the de- 
spondency of true melancholia, still less of the character of 
other forms of insane egotism. The patient (as observed by 
Leidesdorf), though depressed in mind, not only wishes to 
get rid of his malady, but has great faith that he shall do 
so ; a faith which suffers repeated shocks, indeed, from the 
non-success of particular remedies, but quickly revives in 
favour of some new mode of treatment. The eagerness with 
which he pursues the means of cure is the true cause of the 
limitation of his thoughts. 

Next to pseudo-dyspeptic symptoms, and the occurrence 
of pains or anomalous feelings at the pit of the stomach, the 
most common morbid sensations in hypochondriasis are 
probably formication of the skin, and hurning 'pains in the 
course of particular superficial nerves. It is noteworthy 
that, so far as we are aware, the nerve-pains most frequently 
assume the burning type, rather than the lancinating, 
throbbing, or aching forms which neuralgia more commonly 
takes. A common occurrence is the sudden shifting of the 
pains or the sense of formication from one part of the body 
to another, or their sudden extension from a small area 
which they first affected over almost the whole surface of 
the body. Another very frequent subjective symptom is the 
feeling of pain, or great but indescribable uneasiness, deep 
in the heart, or the lungs, or the liver, the bladder, or the 
rectum. The development of the subjective symptoms is 
very often seriously influenced by the fact that the patient 
is driven by his misery to consult medical books, or to pester 
his medical friends with questions bearing on his sufferings ; 
his defective knowledge and distorted fancy lead him to 
apply, a tort et a travers, the scraps of information which he 
picks up, and to imagine, successively, that he has dis- 
covered in himself the signs of one, two, or half a dozen 
serious organic diseases. Attention being thus directed to 
particular organs, the subjective symptoms naturally increase 



294 DISEASES OF THE NEEVOUS SYSTEM. 

and multiply, and the emotional excitement produced also 
frequently sets up severe functional disturbance, such as 
flushings of the face, abdominal pulsation, palpitation of the 
heart, partial suppression of bile and jaundice, or bilious 
diarrhoea ; symptoms which still further confirm the sufferer 
in the belief that he is labouring under serious organic 
disease. A very common delusion is the belief that there is 
fatal heart disease ; and a scarcely less frequent one is the 
persuasion of the patient that he is impotent from sperma- 
torrhoea; this last is of course greatly fostered by reading 
pseudo-medical treatises. In the case of patients whose 
family is strongly tainted with insanity, the anomalous 
sensations often assume a type which approaches to hallu- 
cination or illusion (as where there is the belief that a 
serpent is writhing about in the entrails, &c.), or the 
judgment becomes affected to such a degree that the patient 
entertains preposterous delusions (as that he is made of glass 
and in danger every moment of being broken, that he is 
being magnetised, that people are conspiring to poison him, 
&c.). The delusions sometimes are confined, at any rate for 
a time, to one or two organs, but are nevertheless so 
extravagant that it would really seem no paradox to say 
that the patient has a mad stomach, a mad liver, or a mad 
bladder ; while on all other matters his intellect remains 
healthy, and often unusually acute. But on the subject of 
the protean symptoms of hypochondriasis it is really 
unnecessary to enlarge further, and we may refer those who 
desire to read a truthful and highly picturesque description 
of them to the pages of Burton,^ to say nothing of more 
modern writers. 

Diagnosis. — The diagnosis of hypochondriasis, from mala- 
dies superficially resembling it, is proverbially beset with 
difficulties, and the practitioner can only gain confidence in 
his decision on the more doubtful cases by means of long 
experience. Nevertheless, the general principles on which 
his judgment must be formed are not very difficult to state. 

If the anomalous character of a patient^s subjective sym- 
ptoms points in the direction of hypochondriasis, the very 
first subject of inquiry should be the family history. A 
' 'Anatomy of Melancholy,' pj). 270 — 274. 



HYPOCHONDRIASIS. 295 

well-defined history of insanity in the race would at once 
indicate the probability that the patient's sensations were 
partly illusory, and not referable to their apparent site. On 
the other hand, a decided history of the absence of insanity 
and of the other severe neuroses from the family during two 
or three previous generations, would still more strongly 
suggest that the case was not one of hypochondriasis. The 
next point for investigation would be the mode of com- 
mencement of the illness. A history of the primary 
occurrence of severe bodily symptoms, whether in the shape 
of pyrexia, of disturbance of hepatic or gastric functions, or 
of pain in the course of nerves, is unfavorable to the dia- 
gnosis of hypochondriasis, unless these phenomena were 
preceded or accompanied by psychical changes such as have 
been already described. Even a more chronic development 
of capricious pains, of formication of the skin, of flatulence, 
palpitations, and the like, is not specially indicative of 
hypochondriasis, unless there is unusual anxiety on the 
patient's part, and an egotistic tendency to dwell on his 
sufferings. A great deal may be gathered from considera- 
tions of age and sex. Hypochondriasis is pre-eminently a 
disease of adult and middle life ; it is hardly ever seen before 
puberty, and it very rarely makes its first appearance after 
the age of fifty. It is greatly more common among men 
than among women ; in the latter sex it appears to be 
replaced, for the most part, by hysteria. Still hypochon- 
driasis may occur in women, and the question of diagnosis 
from hysteria, in such a case, becomes important, and may 
be very diSicult. Beyond all other circumstances which 
favour the probability of hypochondriasis is the fact of a 
strong hereditary taint of insanity. The age at which the 
symptoms commence is important ; thus the first appearance 
of hysterical phenomena nearly always takes place between 
the ages of fourteen and thirty, or else at the grand 
climacteric ; and has very commonly a marked relation to 
those changes in the nervous system which correspond with 
the changes of the sexual apparatus ; whereas the develop- 
ment of hypochondriasis is especially associated with the 
circumstances of middle life — in the rich and idle with the 
tedium vitse of a purposeless existence ; in the poor and 



296 DISEASES OP THE NERVOUS SYSTEM. 

anxious with the cares of a family, and perhaps with the 
added misery of a conscious failure in efforts to support 
relations and dependants. Severe moral and emotional 
shocks may be followed either by hypochondriacal or hys- 
terical disorder ; but the latter is the infinitely more probable 
result in women who are not descended of markedly insane 
families, and especially in women who lead busy lives. 

One of the most important questions in diagnosis is the 
decision whether, if hypochondriasis be present, there is not 
at the same time some organic visceral disease ; for it some- 
times happens that the first sign of the occurrence of such 
disease is an outbreak of hypochondriacal symptoms, the 
patient being hereditarily predisposed to the latter dis- 
order, and his nervous system excited to morbid action 
by the irritation of the new organic processes which are 
going on. Of the diseases which have been known to produce 
such an effect, structural changes of the liver, and next to 
them structural changes of the stomach, are probably the 
most frequent examples ; and, after these, aneurisms of the 
great vessels, valvular diseases of the heart, angina pectoris. 
It is unnecessary here, even if there were space, for us to 
go into the characteristic symptoms of these organic diseases. 
The first feature which may lead the physician to suspect the 
existence of organic visceral disease in the midst of sym- 
ptoms which he feels sure are hypochondriacal, is the 
persistence of some one complaint by the patient — e. g. of 
pain in a particular locality ; especially if this be combined, 
always in the same order, with other symptoms that belong 
to the suspected organic disorder, and with which the patient 
is not likely to be acquainted so as to be mentally influenced 
to reproduce them. Thus if, along with a fixed complaint 
of pain in the preecordia increased by swallowing, there is the 
regular occurrence of regurgitation of some of the food very 
shortly after deglutition, it is a case for inquiry as to the 
possible existence of cancerous or other stricture of the 
cardiac end of the stomach, &c. It is needless to say that 
physical signs, when they are present, are the most valuable 
helps in discerning organic disease which is masked by 
hypochondriasis; yet even here there is need for caution. For 
instance, the occurrence of hardness and tumidity in the 



HYPOOHONDEIASIS. 297 

epigastrium or the hypochondrium, in sucli a form as closely 
to imitate a scirrhous tumour (even on repeated examina- 
tions), may be produced by spasmodic contraction of one or 
both recti : in such a case the administration of chloroform 
would at once dismiss the suspicion by dissolving the 
*' phantom ^^ tumour. A circumstance which is always of doubt- 
ful interpretation is the occurrence of wasting, especially if 
combined with jaundice. If this takes place with rapidity, 
it can hardly be owing to hypochondriacal disturbance of 
digestion and assimilation, but is probably due either to the 
generally depraving effect of cancerous or tubercular taint, 
or to direct interference with nutrition from the mechanical 
effects of ulcer, stricture, or tumour, upon some of the chylo- 
poietic viscera. The combination of insidious and un- 
suspected malarial poisoning with hypochondriacal tendencies 
may produce formidable difficulties in diagnosis, which can 
only be overcome by careful study of the patient's past history, 
sometimes by the discovery of enlarged spleen, and- above 
all by the effects of antiperiodic medicines. Another 
variety of blood-poisoning, which in hypochondriacal patients 
may be somewhat masked, is chronic alcoholism ; but the 
symptoms of the latter complaint are, after all, tolerably 
distinct and recognisable from their peculiar grouping, and 
even in a hypochondriac they may generally be identified. 

A more serious difficulty in diagnosis than any which has 
yet been mentioned is the distinction between certain forms 
of hypochondriasis and true melancholia. Given a patient 
with a decided family history of insanity, with a mental 
condition marked by a strong tendency to dwell on complaints 
of bodily misery, and with dyspepsia and flatulence, it may 
be very difficult to say whether or not the case will pass into 
true melancholic insanity. The following case will give a 
good idea of the occasional uncertainty. A postman aged 
forty-three, a widower, was much overworked, and especially 
harassed by having to sort the letters in the morning before 
he started on his beat — a task which had to be hurriedly done, 
and hence gave him much anxiety lest he should make 
mistakes. He applied for relief from dyspepsia and flatu- 
lence and bilious diarrhoea, but at the same time complained 
that his spirits were dreadfully low, that he had thoughts of 



298 DISEASES OF THE NERVOUS SYSTEM. 

suicide, and that he believed he had " something alive in his 
inside." A simple tonic mixture of mineral acid and bark, 
combined with the moral influence of encouraging assurances 
from the physician, did this patient so much good that he 
soon seemed perfectly well, and remained so for some 
months. He then got married again, and his marriage 
apparently embarrassed his means, though not seriously ; but 
his despondency now returned in the form of a belief that 
he and his family would have to go to the workhouse (of 
which there was really not the least danger), and the impulse 
to suicide again became very urgent. At the same time his 
dyspepsia and bilious diarrhoea returned. He applied for 
medical relief, was ordered the same treatment as before, and 
was encouraged to hope for a speedy cure ; but the very next 
day he attempted suicide by completely severing the whole of 
his genitals from his body with a razor. He was taken to St. 
George's Hospital, and with great difliculty kept alive while 
the wound healed. Six weeks after his discharge from the 
hospital he appeared before his former attendant, looking fat 
and fresh-coloured, but more despondent than ever — indeed, 
plainly insane. He was then lost sight of, but there could 
be little doubt that he would get worse, and, if not carefully 
watched, would commit suicide. 

Such a case as the above has little to separate it from 
hypochondriasis except the one important feature of the early 
occurrence of suicidal despondency ; but this feature would 
probably be sufl&cient justification for a decided diagnosis. 
It is only where the hypochondriac patient has been exhausted 
by a long continuance of his sufferings and rendered hope- 
less by the failure of a thousand attempts at cure, that he 
turns his thoughts to self-destruction, and by that time he 
may be considered really insane. Indeed, the hypochondriac 
proper regards the idea of suicide with the utmost repulsion 
and disgust. 

There is no serious difficulty in distinguishing simple 
hypochondriasis from the other forms of insanity. 

Prognosis. — The prognosis of hypochondriasis varies ex- 
tremely, not so much with the apparent severity of the sym- 
ptoms, as with the circumstances under which they arose, 
the length of time during which they have already persisted. 



HYPOCHONDRIASIS. 299 

and above all the degree to which the patient's family has 
been tainted with insanity. But in general it may be said 
that the younger the patient, the shorter the time during 
which he has suffered, the less that the nutrition of the body 
has deteriorated, and, above all, the less of decided family 
taint of insanity that can be traced, the more hopeful is the 
aspect of the case, and vice versa. 

Etiology. — The " causes of hypochondriasis " is an expres- 
sion even more singularly unhappy than the average instances 
of a phraseology of causation applied to those circumstances 
which precede the outward and visible development of func- 
tional disorders. To commence with those influences which 
have a conventional title to be called " exciting " causes, it 
is undoubtedly true that in a considerable number of cases 
the train of disastrous events has seemed to be fired by the 
moral collapse consequent on over-exhausting labour, or bitter 
disappointment of cherished hopes, or on the sudden revela- 
tion to the mind of an idle man that he is a mere burden on 
the face of the earth. Again, it is commonly said that 
reading or conversation on medical topics often frightens 
laymen, and, more rarely, even doctors, into a nervous and 
hypochondriacal frame of mind. There is doubtless some- 
thing to be attributed to such influences, but the most 
thoughtless person could hardly fail to be struck, on reflection, 
with the surprising infrequency of hypochondriasis in com- 
parison with the ubiquitous operation of such influences as 
grief, fatigue, the sense of shameful failure, the habit of 
miserable and heart-wearying idleness, and the practice by 
the laity of reading medical treatises. If we turn to the 
events which would be conventionally spoken of as " pre- 
disposing " causes, we are scarcely likely to be more satisfied 
with the appropriateness of the term " cause ;" though we 
come upon facts of far greater practical value than those 
which have just been mentioned. The fact of hereditary 
insane taint, for instance,' is an antecedent which is observed 
in an immense number of cases, if not in all. The preponde- 
rance of males among hypochondriacs is equally unmistak- 
able, and so is the fact that the bulk of cases occur in persons 
in the prime and vigour of life. It is also an undoubted fact 
that the average level of intellect in hypochondriacs is not 



oOO DISEASES OF THE NERVOUS SYSTEM. 

below^ but rather above, the general standard ; and that 
their bodily health has often been excellent up to the 
moment when the nervous symptoms made their appearance. 
But instead of saying that these circumstances are " causes ^' 
of the disease, it will be convenient to say that they are 
conditions of its occurrence in the following degree and 
manner. A certain number of the descendants of a family 
strongly tainted with insanity will invariably be born with 
peculiarities of the nervous system ; these peculiarities do 
not, probably, consist of recognisable structural faults, but 
rather of tendencies of one or more (pei'haps scattered) 
portions of the central system, to change interstitially in a 
certain morbid direction, at particular crises of life, through, 
which healthy organisms pass unharmed. Arrived at such 
crises the nervous system will surmount them, or will 
succumb, according to the absence or the presence of certain 
external disadvantages. If the morbid change occurs, it will 
not affect the machinery of the intellectual and reflective 
faculties chiefly, perhaps not at all ; its force will be spent 
mainly on that portion of the nervous apparatus which 
performs the function of translating to the mind the percep- 
tions of sensitive nerves at the periphery ; but it is not 
impossible that even the primary morbid action is occa- 
sionally developed in nervous centres which govern secretion 
and other functions of organic life ; and that the dyspepsia, 
and other functional disorders of viscera, may in these cases 
be the direct result of a central disease, instead of reflex 
phenomena dependent upon the condition of consciousness, as 
is probably the case in many instances. In the later stages of 
the malady there can be no doubt that the mental depression 
reacts with great force upon the machinery of organic life, 
disordering secretions and rhythmic motions very extensively. 
The 'pathology of hypochondriasis, in the strict sense of 
the word, does not exist, for there are no anatomical or 
physiological facts upon which it can be based. Morbid 
anatomy has revealed absolutely nothing which in the slightest 
degree explains the occurrence of the disease ; and the 
physiology of the symptoms is to the last degree obscure and 
uncertain in its interpretation. It is only in those cases 
which develop into true insanity, more especially those which 



HYPOCHONDRIASIS. 301 

pass into demeutia, that the brain exhibits any notable 
changes ; and these alterations, when they occur, are no 
proper part of hypochondriasis. It is neither impossible nor 
unlikely that the improved modern methods of examining the 
nervous centres, if they could be applied to the central 
ganglia of certain visceral nerves (and especially to the 
nucleus of the vagus), might detect appreciable changes even 
in the early stages of the disease. But the opportunities 
for carefully examining the nervous symptoms of patients in 
the early periods of hypochondriasis can rarely be obtained, 
and it is probable enough that the question as to the pre- 
occurrence or not of structural changes will never be tho- 
roughly cleared up. 

The treatment of hypochondriasis consists in the use of 
moral and constitutional remedies and of remedies for sym- 
ptoms. 

It is obvious that the first duty of the physician is to 
encourage the hypochondriac to forget his woes ; but nothing 
is so difficult in practice, and that for the best of reasons. 
It is a fallacy to suppose that the sufferings of the patient 
are unreal ; on the contrary, they are most vividly real, 
and it is impossible that he should forget them till they 
cease. Yet the mind has a reflex influence upon the bodily 
disorder, which may be as effective for good as for evil ; and 
this fact may be taken advantage of. The key to the 
moral treatment is the breaking down of the patient's 
morbid self-concentration, and this object may be achieved 
to some extent in many cases by a change in the course of 
his daily life. The class of patients with whom this may be 
most readily carried out are those in whom the constitutional 
tendency to hypochondriasis is aggravated by the ennui of 
an idle life : for these, an active career or pursuit of almost 
any kind is an immense gain ; only the new occupa- 
tion should be one which forces them to mix with the 
world. The isolated activity of the student is no real diver- 
sion from the fancies of hypochondriasis, as the case of Dr. 
Johnson, and of many other famous intellectual workers, 
abundantly proves. It is needless to say that all actively 
depressing influences should be removed, such as immoderate 
venereal indulgence, of whatever kind, or alcoholic intern- 



302 DISEASES OP THE NERVOUS SYSTEM. 

perance. On the other hand, the influence of new emotions 
which tend to lift the patient out of himself can scarcely fail 
to be beneficial ; and it would be a real good fortune to a 
hypochondriac if he could fall in love in a natural and 
healthy manner, or if he could interest himself warmly in 
philanthropic schemes or other plans of public usefulness. 
And, above all, something like a police supervision should be 
exercised as regards his studies, in order that he may be 
rigorously kept from the perusal of medical or other books 
which might remind him of his miseries ; for though we do not 
believe that these things can create hypochondriasis, yet they 
may cei'tainly prevent its cure. It is well understood, 
however, that no good can be effected by simply laughing 
at his narrative of suffering, or bantering him on his fanci- 
fulness ; on the contrary, it is necessary for the physician 
to be interested, and to believe in the reality of his painful 
sensations. If the patient once thinks that the doctor is 
taking pains to get at the secret of his troubles, he will be 
inclined to accept the first word of encouragement the latter 
throws out ; and the reflected influence of reviving hope mil 
be certain to assist recovery. 

The constitutional treatment is to be directed towards 
improving the general nutrition ; and the task here is partly 
that of aiding the primary process of digestion of food, and 
partly that of rendering more active the processes of decom- 
position and exchange in the tissues generally. The hypo- 
chondriac either has a deficient, a capricious, or a ravenous 
appetite, but in any case the primary function of digestion 
is almost always markedly impaired if the disease has lasted 
for any length of time ; and when this depends on a want of 
tone mainly, or a condition of irritation of the stomach (such 
as is indicated by a coated tongue with a red or strawberry 
tip), the use of vegetable bitters and mineral acids will of ten 
do great good. Defective secondary assimilation, which will 
be especially indicated by the condition of the urine, is gene- 
rally much benefited by the use of cod-liver oil for a rather 
prolonged period, if only the remedy can be tolerated by the 
stomach. In cases where the oil cannot be borne, cream, 
butter, or some other form of fat, will often agree, and may 
be made the first stage to inducing the stomach to retain the 



HYPOCHONDRIASIS. 303 

cod-liver oil. Nor is it by any means only in cases where 
there is general emaciation that the administration of fat 
does good ; it is probable that the nutrition of the nervous 
tissues is directly improved by the treatment in many 
instances. The administration of iron is doubtless of great 
use to some angemic patients, and sea-bathing frequently 
appears to exercise a very beneficial influence : but the first 
of these remedies is generally most efficacious when taken in 
the form of the chalybeate waters of some foreign spa ; and 
there is good reason to doubt whether both mineral waters 
and sea-bathing do not owe most of their apparent power to 
the moral influences of travel and change of scene and mode 
of life. The more specific nervous tonics, such as strychnia, 
quinine, or phosphorus, seem to exercise but a doubtful 
and accidental influence. 

The treatment of symptoms is a thing to be eschewed in 
hypochondriasis, with certain special exceptions. While, 
however, it is desirable to avoid concentrating the patient's 
attention on parts which are the apparent seat of mere 
morbid sensations, it is important to relieve him of the dis- 
tress caused by real (though mere functional) disorders of 
the digestive system. Decided acidity of the stomach should 
be counteracted by the use of antidotes, of which none is 
more efficacious than magnesia ponderosa, in ten-grain doses 
thrice daily, or Brandish 's solution of potash, ten minims 
three times a day, with gentian or cascarilla. The excessive 
or too long continued use of alkalies is, of course, to be 
avoided. The distressing flatulence, which is often one of 
the earliest, and also one of the most annoying symptoms, 
is greatly relieved by creosote (one drop in a pill twice or 
thrice a day) or the infusion of valerian. Alcoholic tinc- 
tures should be very cautiously employed, if at all ; for there 
is a real danger of the patient coming* to appreciate the 
comforting sensations given by the spirit so highly, that he 
gradually takes to drink ; this is especially true in the case 
of hypochondriacal women, as it notoriously is in hysteria. 
We may add that it is particularly likely to occur in patients 
exhausted by masturbation or other venereal indulgence. 
The constipation, which is frequently so obstinate and 
troublesome, must be remedied, if it be anyhow possible. 



304 DISEASES OF THE NERVOUS SYSTEM. 

without the use of drugs ; for it is most dangerous to 
stimulate the patient's love of self-doctoring in the direction 
of the habitual use of purgatives. The prescription of fruit, 
green vegetables, &c., as articles of daily food, is a far more 
desirable mode of accomplishing our object ; and the habitual 
practice of active bodily exercise is a powerful aid to the 
same end. 

The question of the quantum et quale of physical exercise 
which may be beneficial in hypochondriasis forms a fitting 
subject with which to conclude our remarks on treatment, 
since this is a remedy which directs itself alike to the moral, 
the constitutional, and the symptomatic condition of the 
hypochondriac. The only rule, however, which it is possible 
to lay down for our guidance in this matter, is the direction 
to employ physical exercise in such a manner and to such 
an amount as shall fully exercise the muscles without ever 
producing severe fatigue, and shall also be amusing to the 
patient. It is a very dangerous error to carry exercise to 
the fatigue point ; a short continuance of such malpractice 
will usually suffice to produce a profound deterioration of 
the vigour of the nervous system, and an aggravation of 
the hypochondriacal fancies. 



ANOEEXIA NERVOSA. 

(APEPSIA HYSTERICA, ANOEEXIA HYSTERICA.)' 



In an address ou medicine, delivered at Oxford in the 
autumn of 1868/ I referred to a peculiar form of disease 
occurring mostly in young women, and characterised by ex- 
treme emaciation, and often referred to latent tubercle and 
mesenteric disease, I remarked that at present our diagnosis 
of this affection is negative, so far as determining any posi- 
tive cause from which it springs ; that it is mostly one of 
inference from our clinical knowledge of the liability of the 
pulmonary or abdominal organs to particular lesions, and by 
proving the absence of these lesions in the cases in question. 
The subjects of this affection are mostly of the female sex, 
and chiefly between the ages of sixteen and twenty-three. 
I have occasionally seen it in males at the same age. 

To illustrate the disease I may give the details of two 
cases, as fair examples of the whole. 

Miss A — , tet. 17, under the care of Mr. Kelson Wright, of the Clapham 
Roaxl, was brought to me on January 17th, 1866. Her emaciation was very 
great {vide Fig. No. i,^ p. 306). It was stated that she had lost 33 lbs. 
in weight. She was then 5st. 12 lbs.; height 5 ft. 5 in. Amenorrhcea for 
nearly a year. No cough. Respirations throughout chest eveiywhere 
normal. Heart-sounds normal. Resp. 12 ; pulse 56. No vomiting nor 

' Reprinted fi-om the ' Clinical Society's Transactions,' vol. vii, 1874, 
p. 22. 

* ' Lancet,' August, 1868. 

^ The woodcuts illustrating this paper are fac-similes of the original pho- 
togi-aphs exhibited at the time the paper was read. 

20 



306 



DISEASES OF THE NERVOUS SYSTEM. 





Miss A — , No. 2. 



ANOREXIA NERVOSA. 307 

diavrha'a. Slight constipation. Complete anorexia for animal food, and 
almost complete anorexia for everything else. Abdomen shrunk and flat, 
collapsed. No abnormal pulsations of aorta. Tongue clean. Urine normal. 
Slight deposit of phosphates on boiling. The condition was one of simple 
starvation. There was but slight variation in her condition, though observed 
at intervals of three or four months. The pulse was notea on these several 
occasions as 56 and 60. Resp. 12 to 15. The urine was always normal, but 
varied in sp. gr., and was sometimes as low as 1005. The case was regarded 
as one of simple anorexia. 

Various remedies were prescribed — the preparations of cinchona, the 
bichloride of mercury, sjrup of the iodide of iron, s^n'up of the phosphate of 
iron, citrate of quinine and iron, &c., — but no perceptible effect followed 
their administration. The diet also was varied, but without any effect upon 
the appetite. Occasionally for a day or two the appetite was voracious, but 
this was very rare and exceptional. The patient complained of no pain, but 
was^restless and active. This was, in fact, a striking expression of the 
nervous state, for it seemed hardly possible that a body so wasted could 
undergo the exercise which seemed agreeable. There was some peevishness 
of temper, and a feeling of jealousy. No account could be given of the 
exciting cause. 

]\Iiss A — remained under my observation from January, 1866, to March, 
1868, when she had much improved, and gained in weight from 82 to 
128 lbs. The improvement from this time continued, and I saw no more of 
her medically. The woodcut No. 2, p. 306, from photograph taken in 
1870, shows her condition at that time. It will be noticeable that as she 
recovered she had a much younger look, corresponding indeed to her age, 
twenty-one ; whilst the photographs, taken when she was seventeen, give 
her the appearance of being near thirty. Her health has continued good. 

It will be observed tbat all the conditions in this case were 
negative, and may be explained by the anorexia which led to 
starvation, and a depression of all the vital functions, viz. 
amenorrhoea, slow pulse, slow breathing. In the stage of 
greatest emaciation one might have been pardoned for assum- 
ing that there was some organic lesion, but from the point 
of vieAV indicated such an assumption would have been un- 
necessary. 

This view is supported by the satisfactory course of the 
case to entire recovery, and by the continuance of good 
health. 

Miss B — , set. 18, was brought to me, October 8th, 1868, as a case of latent 
tubercle. Her friends had been advised accordingly to take her for the 
coming winter to the south of Europe. 

The extremely emaciated look {vide woodcut No. i, p. 308), much 
greater indeed than occurs for the most part in tubercular cases where 



308 



DISEASES OF THE NERVOUS SYSTEM. 




Miss B— No. 2. 



ANOREXIA NERVOSA. 309 

patients are still going about, impressed me at once with the probability 
that I should find no visceral disease. Pulse 50, resp. 16. Physical exami- 
nation of the chest and abdomen discovered nothing abnormal. All the 
viscera were apparently healthy. Notwithstanding the great emaciation 
and apparent weakness, there was a peculiar restlessness, difficult I was 
informed, to conti-ol. The mother added, " She is never tired." Amenor- 
rhoea since Christmas, 1866. The clinical details of this case were, in fact, 
almost identical with the preceding one, even to the number of the pulse 
and respirations. 

I find the following memoranda frequently entered in my note-book : — • 
"Pulse 56, resp. 12; January, 1S68, pulse 54, resp. 12; March, 1869, 
Pulse 54, resp. 12 ; March, 1870, pulse 50, resp. 12. But little change 
occurred in the case iintil 1872, when the respirations became 18 to 20, 
pulse 60. 

After that date the recovery was progressive, and at length complete. 
{Vide woodcut No. 2, p. 308.) 



The medical treatment probably need not be considered as 
contributing mucb to tlie recovery. It consisted, as in the 
former case, of various so-called tonics and a nourishing 
diet. 

Although the two cases I have given have ended in re- 
covery, my experience supplies one instance at least of a 
fatal termination to this malady. When the emaciation is 
at the extremest, oedema may supervene in the lower ex- 
tremities, the patient may become sleepless, the pulse 
quick, and death be approached by symptoms of feeble febrile 
reaction. In one such case the post-mortem revealed no 
more than thrombosis of the femoral veins, which appeared 
to be coincident with the oedema of the lower limbs. Death 
apparently followed from the starvation alone. This is the 
clinical point to be borne in mind, and is, I believe, the 
proper guide to treatment. I have observed that in the 
extreme emaciation when the pulse and respiration are slow, 
the temperature is slightly below the normal standard. This 
fact, together with the observations made by Chossat on the 
effect of starvation on animals, and their inability to digest 
food in the state of inanition, without the aid of external 
heat, has direct clinical bearings ; it being often necessary 
to supply external heat as well as food to patients. The 
best means of applying heat is to place an india-rubber tube, 
having a diameter of 2 inches and a length of 3 or 4 feet. 



310 DISEASES OF THE NERVOUS SYSTEM. 

filled with hot water, along the spine of the patient, as sug- 
gested by Dr. Newiugton of Ticehurst. 

Food should be administered at intervals varying inversely 
with the exhaustion and emaciation. The inclination of the 
patient must be in no way consulted. In the earlier and 
less severe stages it is not unusual for the medical attendant 
to say, in reply to the anxious solicitude of the pai*ents, 
" Let her do as she likes. Don't force food." Formerly I 
thought such advice admissible and proper, but larger expe- 
rience has shown plainly the danger of allowing the starva- 
tion process to go on. 

As regards prognosis, none of these cases, however ex- 
hausted, are really hopeless whilst life exists ; and, for the 
most part, the prognosis may be considered favorable. 
The restless activity referred to is also to be controlled, but 
this is often difficult. 

It is sometimes quite shocking to see the extreme exhaus- 
tion and emaciation of these patients brought for advice ; 
yet, by warmth, and steady supplies of food and stimulants, 
the strength may be gradually resuscitated, and recovery 
completed. 

After these remarks were penned, Dr. Francis Webb 
directed my attention to the paper of Dr. Lasegue (Professor 
of Clinical Medicine in the Faculty of Medicine of Paris, and 
Physician to La Pitie Hospital) which was published in the 
' Archives generales de Medecine,' April, 1873, and trans- 
lated into the pages of the ' Medical Times,' September 6th 
and 27th, 1873. 

It is plain that Dr. Lasegue and I have the same malady 
in mind, though the forms of our illustrations are diffei-ent. 
Dr. Lasegue does not refer to my address at Oxford, and it 
is most likely he knew nothing of it. There is, therefore, 
the more value in his paper, as our observations have been 
made independently. We have both selected the same 
expression to charactei'ise the malady. 

In the address at Oxford I used the term Aj^epsia 

hxjsterica, but before seeing Dr. Lasegue's paper, it had 

equally occurred to me that Anorexia would be more correct. 

The want of appetite is, I believe, due to a morbid mental 

state. I have not observed in these cases any gastric dis- 



ANOREXIA NERVOSA. 311 

order to which the want of appetite could be referred. I 
believe, therefore, that its origin is central and not peripheral. 
That mental states may destroy appetite is notorious, and it 
will be admitted that young women at the ages named are 
specially obnoxious to mental perversity. We might call the 
state hysterical without committing ourselves to the etymo- 
logical value of the word, or maintaining that the subjects of 
it have the common symptoms of hysteria. I prefer, how- 
ever, the more general term " nervosa,^' since the disease 
occurs in males as well as females, and is probably rather 
central than peripheral. The importance of discriminating 
such cases in practice is obvious ; otherwise prognosis will 
be erroneous, and treatment misdirected. 

In one of the cases I have named the patient had been 
sent abroad for one or two winters, under the idea that there 
was a tubercular tendency. I have remarked above that 
these wilful patients are often allowed to drift their own 
way into a state of extreme exhaustion, when it might have 
been prevented by placing them under different moral condi- 
tions. 

The treatment required is obviously that which is fitted 
for persons of unsound mind. The patients should be fed at 
regular intervals, and surrounded by persons who would 
have moral control over them ; relations and friends being 
generally the worst attendants. 

One other case is recorded as addendum to the above, 
in which the details are unimportant. 



The following case was Sir William GulFs last contribu- 
tion to the study of clinical medicine. 

It may interest the readers of the ' Lancet ' to look at 
the accompanying wood engravings, which were made 
from photogi'aphs of a case of extreme starvation (anorexia 
nervosa) which was brought to me on April 2otli of last year 
by Dr. Leachman, of Petersfield. Dr. Leachman was good 
enough subsequently to send me notes of the patient's 



312 



DISEASES OF THE NERVOUS SYSTEM. 



progress ; and afterwards, at my request, the two photo- 
graphs, taken by Mr. C. S. Ticehurst, of Petersfield. The 
case was so extreme that, had it not been photographed and 
accurately engraved, some assurance "would have been neces- 
sary that the appearances were not exaggerated, or even 
caricatured, which they were not. 




Pliotograplied April 2rst, 1887. 



Miss Iv. E — , set. 14, the third child in a family of six, one of whom'died 
in infancy. Father died, aged sixty-eight, of pneumonic phthisis. Mother 
living and in good health. Has a sister the subject of various nervous 
symptoms, and a nephew epileptic. With these exceptions there have been 
no other neurotic cases on either side in the family, which is a large one. 
The patient, who was a plump, healthy girl until the beginning of last year 



ANOREXIA NERVOSA. 



313 



(1887), began early in February, without apparent cause, to evince a repug- 
nance to food, and soon afterwards declined to take any whatever except 
half a cup of tea or cofEee. On March 13th she travelled from the north of 
England, and visited me on April 20th. She was then extremely emaciated, 
and persisted in walking through the streets to my house, though an object 
of remark to the passers by. Extremities blue and cold. Examination 




Photographed June 14th, 1887.^ 

showed no organic disease. Eesp. 12 to 14; pulse 46; temp. 97°. Urine 
normal. Weight 4st. 7 lbs. ; height 5 ft. 4 in. Patient expressed herself as // 
quite well. A nurse was obtained from Guy's, and light food ordered every 



1 This illustration differs fi-om that given in the original paper ; since, the 
negative having been destroyed, it was found impracticable to reproduce the 
woodcut. — Ed. 



314 DISEASES OF THE NERVOUS SYSTEM. 

few hours. In six weeks Dr. Leachmaii reported her condition to be fairly 
good, and on July 27th the mother wrote, "K — is nearly well. I have no 
trouble now about her eating. Nurse has been away three weeks." This 
story, in fine, is an illustration of most of these cases, perversions of the 
" ego " being the cause and determining the course of the malady. As part 
of the pathological history, it is curious to note, as I did in my first papei", 
the persistent wish to be on the move, though the emaciation was so great 
and the nutritive functions at an extreme ebb. 



ox A CKETINOID STATE SUPEHVENING 
IN ADULT LIEE IN WOMEN.^ 



The remarks I have to make upon the above morbid state 
are drawn from the observation of five cases. Of two of 
these I am able to give many details, but the three others 
were only seen by me on one or two occasions. 

Case i. — Miss B — , after the cessation of the catamenial period, became 
insensibly more and more languid, with general increase of bulk. This 
change went on from year to year, her face altering from oval to round, 
much like the full moon at rising. With a complexion soft and fair, the 
skin presented a peculiarly smooth and fine texture, was almost porcellaneous 
in aspect, the cheeks tinted of a delicate rose purple, the cellular tissue 
under the eyes being loose and folded, and that under the jaws and in the 
neck becoming heavy, thickened, and folded. The lips large and of a rose 
purple, aljB nasi thick, cornea and pupil of the eye normal, but the distance 
between the eyes appearing disproportionately wide, and the rest of the nose 
depressed, giving the whole face a flattened broad character. The hair 
flaxen and soft, the whole expression of the face remarkably placid. The 
tongue broad and thick, voice guttural, and the pronunciation as if the 
tongue were too large for the mouth (cretinoid). The hands peculiarly 
broad and thick, spade-like, as if the whole textures were infiltrated. The 
integuments of the chest and abdomen loaded with subcutaneous fat. The 
upper and lower extremities also large and fat, with slight traces of oedema 
over the tibiae, but this not distinct, and pitting doubtfully on pressure. 
Urine normal. Heart's action and sounds normal. Pulse 72 ; breathing 18. 

Such is a general outline of the state to which I wish to 
call attention. 

On the first aspect of such a case, without any previous 

experience of its peculiarity, one would expect to find some 

^ Eeprinted from the Clinical Society's 'Transactions,' vol. vii, 1874, 
p. 180. 



316 CRETINOID STATE IN ADULT LIFE IN WOMEN. 

disease of the heart leading to venous obstruction, or a 
morbid state of the urine favouring oedema. But a further 
inquiry would show that neither condition was present ; nor, 
when minutely studied, is the change in the body which I 
have described to be accounted for from either of these 
points of view. 

Had one not proof that such a patient had been previously 
fine-featured, Avell-formed, and active, it would be natural to 
suppose that it was an original defect such as is common in 
mild cretinism. In the patient whose condition I have 
given above, there had been a distinct change in the mental 
state. The mind, which had previously been active and 
inquisitive, assumed a gentle placid indifference, corre- 
sponding to the muscular languor, but the intellect was 
unimpaired. Although there was no doubt large deposit of 
subcutaneous fat on the extremities, chest, and abdomen, 
the mere condition of corpulency, obesity, or fatness, would 
not in any way comprehend the entire pathology. 

It is common to see patients with a very superabundant 
accumulation of fat in the subcutaneous adipose tissues, and 
on that ground more inactive, without the change in the 
texture of the skin, in the lips and nose, increased thick- 
ness of tongue and hands, &c., which I have enumerated. 
The change in the skin is remai-kable. The texture being 
peculiarly smooth and fine, and the complexion fair, at a 
first hasty glance there might be supposed to be a general 
slight oedema of it, but this is not confirmed by a future 
examination ; whilst the beautiful delicate rose-purple tint on 
the cheek is entirely different from what one sees in the 
bloated face of renal anasarca. This suspicion of renal 
disease failing, any one who should see a case for the first 
time might suppose that the heart was the faulty organ, and 
that this general change in the features and increase of 
bulk were owing to venous congestion. But neither would 
this be confirmed by an exact inquiry into the cardiac con- 
dition. 

I am not able to give any explanation of the cause which 
leads to the state I have described. It is unassociated with 
any visceral disease, and having begun appears to continue 
uninfluenced bv remedies. 



CKETIXOID STATE IN ADULT LIFE IN WOMEN. 317 

Case 2. — P. M — , ajt. 40, a married woman, having had live children 
and living in good circumstances, came under mj observation in 1866 
complaining of general languor. 

Heat was normal. Pulse 60. Catamenia too profuse. There had been 
gradual and general increase of bulk. The features had become broad and 
flattened, the skin was peculiarly fair and fine and soft, with a very delicate 
rose-bloom on the cheeks. The cellular tissue about the eyes was thrown 
into folds, giving the impression when cursorily looked at, of being (Edema- 
tous. The eyes were brigbt, the lips were thickened, and of a light rose- 
purple. Tongue large, the speech guttural, and, as in the former case, as if 
the tongue were rather unwieldy. The sounds and impulse of the heart 
were normal, breathing was normal, urine normal. In fine, there was no 
discoverable change in any of the viscera, and the morbid state complained 
of seemed to be some primary change in the integuments, the muscles, and 
the nervous tissues of the cerebro-spinal system. This change continued to 
advance, so that in 1873 I made the following notes : 

" Tongue large ; false teeth cannot be worn, as tongue bitten by them. 
Lips large, thick, of a light rose (venous) tint. Features broad. Tissue 
under eyes loose, suggesting cedema. Fine delicate rose-tint on cheeks. 
Hair soft. Xeck thick. Skin and subcutaneous textures lying in resisting 
folds. Hands broad and spade-like, the textures suggesting cedema, but 
not pitting. Much subcutaneous fat on chest, abdomen, and extremities. 
Thighs thirty-nine inches in circumference. Mind generally placid and 
lazy, but liable to being occasionally suddenly ruffled. Heart's action and 
breathing normal. Urine normal. Catamenia continue rather profuse." 

The following is from a letter written by me on this 
case, March 7th, 1873, and fairly expresses my views of it at 
that time, which was seven years after my first observation 
of it. 

" I believe it to be a rare form of constitutional disorder 
without any internal visceral disease, but characterised by 
great inaptitude to spontaneous exertion both of mind and 
body. The deposit of fat and the changes in the skin and 
connective tissues correspond to a languid condition of the 
venous circulation, but without any tendency to oedema, or 
any sign of cardiac defect. 

" No doubt, under the stimulus of external circumstances, 
there is a response of mental activity which seems to prove 
that the mind requires but an exei'tion of the will to work 
up to its normal level. Though this be theoretically pos- 
sible, I doubt if it be practically so in this state. The 
peculiar condition of the nervous system will, I believe, be 
best understood by reference to the external condition of the 



318 CRETINOID STATE IN ADULT LIFE IN WOMEN. 

frame ; for although I do not think the nervous centres have 
undergone any discoverable anatomical change, nor is there 
any evidence that the intellect is materially injured, I believe 
the nervous power is upon the whole lessened, and hence 
have arisen the changes in the temper, and the attacks 
which have been described to me. 

" The best suggestions I can make are to let events take 
their course very much, maintaining the strength by simple 
regimen and fi'esh air, and by the occasional or more or 
less continuous use of such remedies as quicken the peri- 
pheral venous circulation — hot-air bath or warm bath, 
frictions, &c. ; but the general good effect will, I think, be 
limited." 

To those about such a patient the whole morbid condition 
is likely to be attributed to indolent habits, and the apparent 
incapacity for exertion to be deemed dependent upon mere 
inertness of the will. No doubt extreme circumstances have 
a distinct influence upon these as upon other patients, but I 
believe the disinclination to mental or muscular activity is 
largely pathological. 

There is certainly a degree of habitual and mental indif- 
ference, though this may under occasional circumstances be 
obviated, since the intellect seems to be unimpaired. It 
will be noticed that I have designated this state cretinoid. 
My remarks are rather tentative than dogmatical, my hope 
being that once the attention of the profession is called to 
these cases, our clinical knowledge of them will in proportion 
improve. That the state is a substantive and definite one, 
no one will doubt who has had fair opportunity of observing 
it. And that it is allied to the cretin state would appear 
from the form of the features, the changes in the lips and 
tongue, the character of the hands, the alteration in the 
conditions of locomotion, and the peculiarities, though slight, 
of the mental state ; for, although the mind may be clear 
and the intellect unimpaired, the temper is changed. 

In an interesting paper ^ on sporadic cretinism occurring 
in England, my friend Dr. Fagge has given a case which 
began as late as the eighth year, in a subject previously 

' ' Medico-Chirurgical Transactions,' 1871, p. 155. 



CEETINOID STATE IN ADULT LIFE IN WOMEN. 319 

healthy and well developed ; and he states that in this case 
the physical configuration was alone manifested, or at any 
rate that any change in the mental powers was doubtful ; 
and he adds '•' it may therefore be interesting to speculate as 
to what character would be present should the disease (if 
that be possible) arise still later in the course of adult life." 

In the same paper Ave find that ''in the report of the 
Sardinian Commission it is stated that, according to infor- 
mation received from medical men practising in infected 
districts, and according to all those who have written on 
this degeneration, there is no example in which, after the 
seventh year, a healthy child has become a cretin.^' And 
the Commission further quote with approval the statement 
of Maffei (who practised for a long time where cretinism 
was endemic, and who therefore had good opportunities of 
observing it), "that the period within which cretinism may 
commence is limited by the fourth year of life. . . It 
must, indeed, be mentioned that Eosch has recorded two cases 
in which the disease is said to have begun respectively at 
five years of age, and between seventeen and eighteen 
years." 

It is to be borne in mind that these statements are appli- 
cable only to endemic cretinism, and therefore the objections 
from the experience of those who have observed only the 
endemic cases will be of less value. 

The occasional occurrence of cretinism in children of 
healthy parents, and living in healthy districts in this 
country, is now well known. But our experience as to its 
development at different periods of childhood is of the most 
limited kind. The whole information on the point is con- 
tained, I believe, in Dr. Fagge's paper, and is illustrated by 
the second case given. 

In the cretinoid condition in adults which I have seen, 
the thyroid was not enlarged ; but from the general fulness 
of the cutaneous tissues, and from the folds of skin about 
the neck, I am not able to state what the exact condition of 
it was. The supra-clavicular masses of fat first described 
by Mr. Curling, and specially di'awn attention to by Dr. 
Fagge as occurring in cases of sporadic cretinism in children, 
did not attract my attention in adults. The masses of 



320 SPORADIC CRETINISM. 

supra-clavicular fat are not infrequent in tlie adult without 
any associated morbid change whatever. 



On November 23rd, 1883, a discussion arose at the 
Clinical Society on a "typical case of Myxoedema" which was 
shown by Dr. Drewitt.^ This debate elicited the following 
letter from Sir William Gull addressed to the * Lancet.^ 

SPORADIC CRETINISM. 

To the Editor of ' The Lancet.' 

Sir, — I shall be obliged if you will find room for the 
following quotations from my late friend Dr. Hilton Fagge's 
paper on " Sporadic Cretinism." You will see from it that 
the sporadic cretinoid state has long been under consideration 
— at Guy^s, at least, — and that such cases were brought 
forward in the clinical teaching there. The very great 
pathological value of Dr. Hilton Fagge^s paper was his 
referi'ing the state to atrophy of the thyroid, as will be seen 
in the last paragraph. We must all deeply regret that his 
very clear and highly informed mind should have been 
wanting to us in this interesting discussion. 

Dr. Fagge writes as follows : — " The subject of sporadic 
cretinism appears hitherto to have attracted very little 
attention. I am not aware that anything has been written 
concerning it, with tbe exception of the papers which have 
already been quoted. In Virchow's great work on tumours 
I have failed to find any reference to it, either in the 
chapter on goitre (in which ' endemic cretinism ' is discussed 
at some length) or in that on fatty tumours. It is, 
therefore, especially incumbent on me to state that, in the 
course of his clinical teaching at Guy^s Hospital, Dr. Gull 
some years ago made me acquainted with many of the prin- 
cipal features exhibited by these cases. So far as I remember, 
the characters on which he laid most stress were the broad 
face, the flat nose and thick lips, the broad hands and feet, 
and the mild, tranquil disposition, so different from 
the mischievous tendencies of the idiots with whom these 
^ Clinical Society's ' Transactions,' vol. xvii, 1884, p. 49. 



SPORADIC CRETINISM. 321 

children are so generally associated. I do not think that Dr. 
Gull's attention had at that time been drawn to the presence 
of the peculiar tumours above the clavicles. He called the 
disease cretinism. . . . It is at this point, as I think, that 
the occurrence of sporadic cretinism, in association with an 
absence of the thyroid body, may be brought to bear upon 
the theory of the subject. We have but to suppose that the 
healthy thyroid body is capable of exerting such a counter- 
acting influence, and that in most parts of England the 
cause of cretinism acts only with a low degree of power, and 
we can then at once see why a form of cretinism should show 
itself when the thyroid body is atrophied." — {' Med.-Chir. 
Trans.,' 1871, vol. liv, pp. 166, 169.) 

" Your obedient servant, 

'' William W. Gull. 
" Beook Steeet ; December, 1883." 



Note. — On December 14th, 1883, a committee was nomin- 
ated by the President of the Clinical Society (with Dr. Ord as 
Chairman, and Dr. Hadden as Hon. Sec.) to investigate and 
report on " Myxoedema," the name which had been given by 
Dr. Ord to the disease called by Sir William Gull '' the 
Cretinoid State." 

This committee issued a " Report on Myxoedema " as a 
supplement to vol. xxi of the ' Clinical Society's Trans- 
actions,' 1888. This report contains a summary of 109 
cases — Ed. 



21 



SECTION II. 



DISEASES OF THE VASCULAR 
SYSTEM. 



ON THE 
PATHOLOGY OF THE MORBID STATE 



COMMONLY CALLED 



CHEONIC BRIGHT'S DISEASE WITH 
CONTRACTED KIDNEY. 

(" ARTERIO-CAPILLARY FIBROSIS.")^ 



De. Bright and subsequent pathologists have fully recog- 
nised that the granular contracted kidney is usually associated 
with morbid changes in other organs of the body. The 
disease in the kidney and the co-existent morbid changes 
are commonly grouped together and collectively termed 
" chronic Bright's disease/' 

In this communication we propose to consider the patho- 
logy of this morbid condition. We are induced to do this 
because our observations tend to show that the present 
prevailing pathological theories do not fully comprehend 
the whole history of the disease. 

It is, we believe, generally assumed that the kidney is the 
organ primarily affected, and in consequence a cachexia is 
induced through which other organs subsequently suffer and 

1 By Sir William Gull, Bart., 3I.D., D.C.L., F.K.S., and Henry G. 
Sutton, M.B., F.E.C.P. Reprinted from the ' Medico-Chirurgical Trans- 
actions,' vol. Iv, 1872, p. 273. 



326 DISEASES OF THE VASCULAR SYSTEM. 

undergo chronic changes . How far this opinion is well 
founded we now proceed to examine. 

It will be advantageous first to consider the morbid changes 
in the kidneys, and subsequently the morbid changes which 
occur in other parts of the body. 

The morbid anatomy of granular contraction of the kidney 
is generally so well known that it is needless here to fully 
describe it, though it is necessary to recount some of the 
histological changes which may be observed in this state. 

For our examinations some sections were made of the 
diseased kidneys without any hardening process ; others were 
made after freezing : some sections were faintly stained by 
a weak solution of nitrate of silver, others by carmine, and 
others were left in a natural state. The examination was 
made by -^ and I inch object-glass, and the following changes 
were noticed. 

A fine fibroid or hyaline-fibroid substance was seen between 
the convoluted tubules, which made the tubules appear wider 
apart than normal. 

In some parts this substance had a homogeneous appearance, 
in others it had a striated or fibroid appearance like a net- 
work, and contained minute indistinct nuclei (?), and in 
others it had a coarser and more defined fibre-like character. 
This substance was seen in considerable quantity round the 
Malpighian bodies, and in still greater amount in and around 
the walls of the minute arteries. In some renal arterioles 
injected with Beale's blue translucent fluid the elastic tissue 
of the tunica intima was normal. The muscular tissue ap- 
peared to be changed in some of the vessels — it seemed thicker 
than natural, particularly when the arterioles were viewed 
longitudinally. The muscular nuclei were indistinct, and 
many of them were so altered as hardly to be recognisable. 
External to the muscular nuclei there was a quantity of 
hyaline-fibroid substance, and the layer formed by this 
material was much thicker than the muscular layer (Plate 
VI, fig. 7) . This hyaline-fibroid was in some of the arterioles 
bounded externally by a few coarser fibres ; in some it merged 
imperceptibly into the fibroid tissues lying between the 
tubules. The arterioles were often very much thickened and 
tortuous. The lumen of some of them was encroached upon 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 327 

and narrowed, and in some it seemed completely obliterated. 
The morbid material here alluded to had in and around the 
walls of some of the arterioles very little hyaline appearance, 
but was more coarsely fibrous. Many of the convoluted 
tubules were not appreciably altered, except that their 
epithelium was more or less granular. Others were much 
shrunken and wasted. Here and there a quantity of the 
fibroid material was noticed, arranged in a concentric 
manner ; and in the centre of the coil were a few indistinct, 
shrivelled, scarcely recognisable epithelial cells. These 
fibroid coils apparently enclosed atrophied tubules. Some 
of the tubules were irregularly dilated, or apparently formed 
a number of cysts. In some situations almost all trace of 
tubular structure had disappeared, and scarcely anything 
but fibroid tissue remained. When the cortex was very much 
contracted the Malpighian bodies were found lying very 
much closer together than normal, and surrounded by a con- 
siderable quantity of fibroid tissue (see Plate V, fig. i). 

In an early stage of granular contraction of kidney, when 
there are no changes appreciable to the naked eye, except 
that the surface. of the kidney is, as technically called in the 
post-mortem room, " coarse,'^ the following alterations may 
be observed. In the walls of some of the minute arteries, 
and also outside and around them, there appears to be an 
excess of fibroid tissue, and the arteries in consequence seem 
thicker than normal. The number of arterioles thus affected 
varies very much. Those most altered are in the cortical 
parts. In making this observation we are well aware that 
there is normally more or less of areolar tissue around the 
minute renal arteries, therefore it is difficult with any degree 
of certainty to appreciate any slight increase in such tissue ; 
but after careful observation it seemed to us that the outer 
coats of the arterioles even at this early stage were thick- 
ened by increase of fibroid tissue. The muscular tissue did 
not appear increased. The intertubular tissue seemed also 
altered in some parts. It was abnormally distinct and 
clearly defined. The fibre-like appearance was unduly 
marked as contrasted with the normal kidney intertubular 
structure. Immediately under the capsule, and corresponding 
to the depressions of the granular surface, fibroid tissue ex- 



328 DISEASES OF THE VASCULAR SYSTEM. 

tended inwards, obscuring and destroying the tubular struc- 
ture. This appearance has been well described by Dr. 
Dickinson. Amongst this fibroid tissue we occasionally 
observed a number of corpuscles and nuclei. 

It remains for us to describe the morbid changes in the 
epithelium of the convoluted tubules. Dr. Johnson (p. 219, 
first edition of his work on 'Kidney Diseases') states that in 
the early stage of the disease now under discussion the only 
deviation from the usual appearance is in the epithelial ceils 
of the convoluted tubules. ''The epithelial cells are/' he says, 
" opaque, and have an unusual finely granular appearance : 
in some of the tubules there is an appearance as of entire 
cells having been shed filling the tubules and rendering them 
opaque ; in others there is an equal filling and opacity of the 
tubules from contained epithelium in a disintegrated condi- 
tion." Dr. Dickinson states, on the contrary, that in the 
early stage of granular renal disease the epithelium is as in 
healthy kidneys, but it is altered where tbe kidneys are 
greatly contracted. We also ourselves have observed in some 
specimens that the epithelium cells were finely granular, but 
natural in all other respects. In others we have noticed a 
quantity of granular or homogeneous matter that rendered 
the tubules more opaque, and almost completely concealed 
the epithelium. In the advanced stages of granular disease 
the cells were very irregular in shape and shrivelled ; their 
nuclei were indistinct. In some spots the epithelial cells 
were absent, and in other tubules of the same specimen the 
epithelium was observed to be not appreciably altered. 

In the kidneys which had recently been the seat of acute 
nephritis the epithelium was more opaque, and contained 
granules. Here and there only was an epithelium cell in itn 
natural position, the rest of the tubule being denuded, or the 
cells concealed by granular matter. 

From the descriptions given it would appear that Dr. 
Johnson, Dr. Dickinson, and ourselves have observed similar 
changes in the epithelium. From these appearances Dr. 
Johnson draws the conclusion that the secreting cells of 
the kidney have undergone a primary pathological change. 
He refers this change in the cells to their removing from the 
blood some poisonous materials with which it is charged, and 



CHEONIC BRIGHT S DISEASE WITH CONTRACTED KIDNEY. 329 

SO becoming themselves changed in appearance and struc- 
ture. We submit that it is not necessary to adopt Dr. 
Johnson's explanation in order to account for these appear- 
ances and alterations in the epithelium. The granular 
appearance of the epithelium is by no means confined to 
Bright's disease. It is usual to find it in kidneys which 
present no sign of disease except merely mechanical venous 
congestion. This form of congestion is seen more or less in 
by far the majority of post-mortem examinations. It occurs 
after death from various causes, and it is certainly not 
dependent on any definite pathological state beyond that of 
venous obstruction, which notoriously always takes place to 
a greater or less extent during the process of dying : — in 
consequence of obstruction to the circulation through the 
right side of the heart the blood accumulates in the vena 
cava and in the renal and other veins ; the renal venules 
and capillaries become distended, and serum with albumino- 
fibrinous contents transudes into, the tubules, the urine 
becomes albuminous, and the epithelial cells are coated with 
granular fibrinous matter. This exudation may be moulded 
in the tubules, and form hyaline or other casts, which may 
be retained in the tubules or passed in the urine.^ Kidney 
epithelium may also be shed as the epithelial cells of the 
bladder may soak off during or after death. Urine con- 
tained in the bladder is notoriously commonly albuminous 
after death, and charged with columnar and other epithelium. 
In such cases there is often no evidence of kidney or 
bladder disease. It appears to us, therefore, that Dr. 
Johnson has attached undue importance to these slight 
changes in the epithelial tissue, whilst the greater changes 
which are seen in the advanced stage of the granular renal 
disease may be regarded rather as a consequence than as a 
cause of the atrophy of the kidney tubules. Our observa- 
tions, on the contrary, seem to show that the visible morbid 
changes in granular contracted kidneys are due to the 
primary formation of " fibroid '' or '' hyaline-fibroid " sub- 
stance in the intertubular parts, including the vessels, and 

' Recent observations on the minute anatomy of the kidney raise a doubt 
whether casts formed in the convohited tubercles of the cortex can escape 
from them. 



330 DISEASES OF THE VASCULAK SYSTEM. 

to atropliy of the tubular and intra-tubular structures of tlie 
kidne3^^ 

This formation commences in different parts of the kidney 
commonly near the surface, but it also seems to us to com- 
mence in the outer coats of the arterioles and in the walls 
of the capillary vessels. From these parts it extends round 
the convoluted tubes and Malpighian bodies. This fibroid 
or hyaline-fibroid substance subsequently contracts and draws 

^ A criticism as to the method of preparation of specimens examined was 
made by Dr. G. Johnson, in reply to which the following letter was written 
to the ' British Medical Journal' (June 15th, 1872) : — Ed. 

" Aeteeio-capillaet Fibrosis. 

" Sir, — We think it our duty to refer to a short and extempore paper by 
Dr. George Johnson in your last issue, in which he makes some remarks 
upon arterio-capillary fibrosis. 

" Dr. Johnson seems to draw conclusions, adverse to our observations, from 
the vessels of the pia mater of the sheep acted upon by acetic acid and glyce- 
rine. Dr. Johnson placed such a vessel before us, but without informing us 
previously what operation it had undergone ; and it appeared to both of us 
that the tunica adventitia was abnormally thick. This admission seemed at 
the time to be eminently satisfactory to Dr. Johnson, as conclusively reduc- 
ing to an absurdity all our previous observations. 

" In reply to this, we desire to say no more than that we have no precise 
knowledge of the effect of the action of acetic acid and glycerine on the 
vessels of a sheep's pia mater. It is not a subject to which we have directed 
our attention. But we are able to say that the healthy vessels of a sheep's 
pia mater, not so acted upon by acetic acid (which reagent is well known to 
swell out the tunica adventitia), do not present the appearances simulating 
those described in our paper ; and we now repeat, for the information of 
your readers, that in the investigations we have conducted neither acetic 
acid nor any other reagent which could distort the tissue was used. We 
may further add that both the diseased and healthy specimens were prepared 
and mounted by exactly the same methods, so as to form ground for strict 
comparison. 

" A matter of so great importance as that in question cannot be decided 
by any ex parte evidence one way or the other. It demands, and will, we 
have no doubt, obtain a full investigation of competent judges, more unbiassed 
than we ourselves or Dr. Johnson can be. Why the vessels from certain 
subjects presented none of the changes described by us, whilst the vessels 
from others having renal and cardiac disease did present them, though both 
were prepared in the same way, we must leave Dr. Johnson to explain. 

" We are, &c. 

(Signed) " William W. Gull. 
(Signed) " Hexey G. Sutton." 



CHUONIC BEIGHT's DISEASE WITH CONTKACTED KIDNEY. 331 

tlie Malpighian bodies togetlier, compresses the urinary 
tubules and vessels, and may entirely obliterate them,^ 
This thickening of the capillary walls and the diminished 
calibre of some of the arterioles must naturally interfere 
with the nutrition of the tissues, and tend to produce further 
atrophy. Owing to these changes in the capillaries and 
arterioles the quantity of blood passing to the secreting cells 
would be lessened, and in consequence diminished activity 
in the secreting function would occur and promote atrophy 
even in normal epithelium. 

We would not, however, maintain that the changes in the 
epithelium must be entirely secondary, for changes may be 
going on in it coincident with the hyaline-fibroid formation 
in the vessels. 

AVhere the kidney disease was far advanced hyaline-fibroid 
changes were seen in the minute renal arteries precisely 
similar to those observed in the arterioles of the pia mater 
and of other parts of the body. Where the kidney disease 
was in an early stage the tissue around the arterioles of the 
kidney and between the tubules had a sharply defined, some- 
what distinctive appearance. We have observed a similar 
appearance in the minute arteries of the pia mater. 

Our examinations have shown us that this hyaline-fibroid 
formation commences, as regards the pia mater, in the outer 
coats of the arterioles and in the walls of the capillaries 
themselves ; and observing that the same kind of formation 
occurs in the arterioles and capillaries of the kidney, we are 
led to infer that this change begins in the kidney as in the 
pia mater in the walls of the arterioles and capillaries, and 
subsequently extends to the surrounding structures. 

We have now to consider the other pathological changes 
which make up the morbid condition known as chronic 
Bright's disease with contracted kidneys. 

Of these the most important and, as we think, essential 
and primary, are the changes in the vascular system, more or 
less general throughout the body. 

Dr. Bright and subsequent observers have recognised 
that arterial changes are part and parcel of this state. 

Dr. George Johnson, in his work on ^Diseases of the 
1 See Plate V, fig. i. 



332 DISEASES OP THE VASCULAE SYSTEM. 

Kidneys/ published in 1852, says that the walls of the 
minute renal arteries are usually much thickened, and that 
this is due to hypertrophy of their muscular layer. 

Dr. Wilks, in the ' Guy's Hospital Eeports ' published in 
1853, remarks that the occurrence of diseased arteries in the 
chronic form of Bright's disease is well known. It is neces- 
sary we should state that both he and Dr. Bright referred 
to atheromatous changes, and to the thickening which occurs 
in the larger and moderate- sized arteries — to changes in 
arteries visible, in fact, to the naked eye. Many other 
writers have made the same observations, but it is notorious 
that atheroma is common in the large vessels, not only in 
Bright's disease, but in other maladies ; still there can be 
no doubt that it is exceedingly common in granular degene- 
ration of the kidneys. Dr. Dickinson found it in the pro- 
portion of 52 per cent. Dr. George Johnson a few years 
ago showed that not only were the microscopical arteries of 
the kidneys thickened, but that the minute arteries of the 
skin and other parts of the body were similai-ly changed, and 
he attributed the change to hypertrophy of their muscular 
tissue. 

Our observations confirm the opinion that the minute 
arteries are thickened in chronic Bright' s disease, and we 
gladly acknowledge the debt the science of medicine owes 
to Dr. George Jolmson in so distinctly insisting upon the 
fact. 

Dr. Beale has also confirmed the accuracy of Dr. Johnson's 
observations as regards the thickening of the minute renal 
arteries, and he expressed an opinion that this is due 
not to hypertrophy of the muscular layer of the vessel ; 
and he has stated that the outer layer of these vessels is 
thickened. 

We have examined by aid of the microscope a large 
number of vessels taken from bodies in which there was more 
or less chronic disease of the kidneys, chiefly granular de- 
generation, and we now desire to bring the result of our 
observations under the consideration of the Society. 

For the purposes of such examination we chiefly selected 
the vessels of the pia mater, since they offered the greatest 
facilities for our purpose, and most of the descriptions of the 



I 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 333 

vessels and the measurements mentioned herein have there- 
fore reference to the minute arteries of the pia mater. In a 
few specimens the arteries were injected, but the major part 
were in the natural state, or merely stained. The portions 
of pia mater were usually taken from the under surface of the 
cerebrum, where the membrane is thin. Afterwards the 
specimens were stained in carmine, and subsequently mounted 
in glycerine and camphor water. The vessels were then 
examined by i- or |^-inch object-glass, and a first or second 
eye-piece. The outlines of some of the arterioles of each 
specimen were drawn by means of the camera lucida, and 
measured by a scale divided for the sake of convenience into 
.^ Q I ,-, ,, parts of an inch. This scale was adopted because it 
allowed of the estimation of minute differences. 

It will be useful if we here mention that we generally 
found in the ai'terioles measuring about -rxnru part of an inch in 
diameter, that the lumen of the vessel was about twice as 
great as the thickness of its wall ; i. e. on observing the 
vessel through the microscope we found the thickness of its 
two sides or walls was equal to the lumen. 

In the larger arterioles the relative width of walls and 
lumen was different, the lumen being proportionately larger. 
In nearly all the cases from which the diseased vessels were 
taken the kidneys were more or less granular, and some much 
contracted. In a few cases only were the kidneys large, 
white, and mottled. The condition of the viscera is briefly 
given in the report of the cases, the details of which are 
recorded in the appendix to this paper. 

The large arteries are usually not much thickened in 
chronic Bright^s disease, but occasionally their outer layer is 
indurated and thickened by this fibroid substance. The 
greatest amount of thickening occurs in the coats of the 
arterioles and capillaries. 

The outer layer of the arteries, measui-ing about -j-oinj ^^ 
an inch in diameter, are also not unfrequently thicker than 
natural. The degree in which the affected vessels are altered, 
and the extent to which the morbid change is diffused over 
the vascular system of the different organs, vary very much 
in different cases. In some, almost all the arterioles seemed 
more or less affected, in others only an arteriole here and 



334 DISEASES OE THE VASCULAE SYSTEM. 

there, the remaining vessels not being greatly if at all 
altered, though fi'equently their outline is more cleai'ly 
and sharply defined than natural. A practised eye can 
usually recognise this early stage of change by this sharply 
defined outline. In consequence of the occasional limitation 
of the morbid change to a few arterioles, care is requisite in 
making an examination, or the diseased vessels may easily be 
overlooked. 

The morbid change in an affected vessel is by no means 
necessarily uniform throughout its length, and may not 
extend to the branches it gives off. The lumen of the 
affected arterioles is sometimes distinctly lessened, and the 
diseased vessels are not unfrequently tortuous, whilst in the 
walls of some of the minuter ones it is common to find 
groups of fat-granules aggregated together. The morbid 
changes vary according to the size of the vessels affected. 
In the larger ones, in which the three coats are distinct, the 
inner layer (tunica intima) is sometimes thickened to a 
marked degree. When this happens the elastic tissue is seen 
to form the inner edge of the arterial wall, and outside this 
the tunica intima has a fine fibrous or molecular appear- 
ance. 

The muscular coat is also variously altered. Thus where 
seemingly normal, if placed, as fresh as possible, in a strong 
solution of carmine for about twelve hours, the nuclei do not 
absorb the carmine so readily as in healthy vessels. This is 
a very distinct difference. The muscular layer seems also 
often relatively increased. This appearance is, however, to 
us equivocal, for with this apparent increase it is common to 
find, even in the same vessel, the muscular tissue wasted, and 
the nuclei irregular in shape, or reduced to small globular 
bodies, having the appearance of large fat-granules. The 
muscular coat may be, in fact, degehoT-ated into granular 
matter at one part, whilst in a contiguous portion of the 
vessel it may seem to be relatively increased. The exami- 
nation of this point which refers to the change in the 
muscular coat has much occupied our attention, but we have 
failed to discover evidence of the muscular hypertrophy so 
much insisted upon by Dr. George Johnson. Outside the 
muscular coat the morbid changes, to which we have already 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 335 

referred wlien describing the changes in the kidney, are well 
marked in the diseased vessels. The outer portion o£ the 
altered arterioles, as seen under the microscope, is commonly 
bounded by a few well-defined fibres of white fibrous tissue, 
within which, and immediately in contact with the muscular 
layer, there is a more or less homogeneous hyaline formation. 
Where this hyaline substance is in contact with the fibrous 
outer layer it has afibrous appearance (see PI. V, fig. 4). The 
general aspect of the affected vessels might give, as Dr. G. 
Johnson affirms, an appearance of true hypertrophy, but after 
full examination it seems to us the whole is due to a moi-bid 
process, and not to an increase of normal nutrition, this 
morbid process giving rise to the formation of the hyaline- 
fibroid substance we have described. In the otherwise 
homogeneous hyaline substance, ill-defined nuclei or corpus- 
cles are often seen. These corpuscles cannot, when fully 
examined, be mistaken for normal muscle nuclei, since they 
are irregularly disposed in the tissue, and waiting in that 
definition characteristic of normal elements. Although in 
the more characteristically affected vessels the " hyaline" 
substance is, as stated, more or less homogeneous, still this is 
by no means uniform, for not only may it contain the bodies 
just referred to, but it may itself be more or less replaced 
by coarse fibroid and granular material. 

The change from the " hyaline '^ to the " fibi'oid " charac- 
ter is probably due to slowness of formation, as it is more 
common in aged persons. It is to be stated that the fibroid 
changes do not occur in the smallest of the capillary arteri- 
oles. In these the homogeneous or nearly homogeneous 
'' hyaline " change alone occurs. 

The moi'bidappearances here described were chiefly studied 
in the minute arteines and larger capillaries of the pia 
mater, but, as we have said, the same may be seen in the 
arterioles of the kidneys, and, we may now add, of the skin, 
of the stomach, of the spleen, lungs, heart, retina, &c.^ 

In the arterioles of the spleen and lungs the morbid sub- 
stance was more coarsely fibroid, and the pure hyaline change 
less distinct. 

In reference to the seat of the hyaline-fibroid formation, 
' Plate V, fig. 2 ; Plate VI, fig.- i. 



336 DISEASES OF THE VASCULAR SYSTEM. 

we cannot pass over the question which will probably be 
raised by those histologists who believe in the existence of 
perivascular sheaths of the minuter vessels. On the exist- 
ence of such canals we express no opinion, but assert only 
that the morbid changes we have noticed occur chiefly out- 
side the muscular layer. 

The following is a general summary of our microscopical 
observations : 

1 . That the arterioles throughout the body in that condition 
usually called chronic Bright^s disease with contracted kidney, 
are more or less altered. 

2. That this alteration is due to a " hyaline-fibroid ^' forma- 
tion in the Avails of the minute arteries, and a '' hyaline- 
granular" change in the corresponding capillaries (see PI. YI, 
figs. I, 2). 

3. That this change occurs chiefly outside the muscular 
layer, but also in the tunica intima of some arterioles. 

4. That the degree in which the affected vessels are altered, 
and the extent to which the morbid change is diffused over 
the vascular system of the different organs, vary much in 
different cases. 

5. That the muscular layer of the affected vessels is often 
atrophied in a variable degree (see PL VI, fig. 3). 

In order to ascertain the extent to which this change in 
the vessels existed, the pia mater was examined in a large 
number of cases of persons who had died of various diseases. 
Fifty-five cases were thus examined, and the result is found 
in the appendix given, and shows that this "^ hyaline-fibroid " 
change was associated with granular contraction of the kid- 
neys in most of the cases ; but, in some few, the vessels of the 
pia mater had largely undergone this change ; and the heart 
was hypertrophied, whilst the kidneys remained healthy.^ 

These examinations also showed that, in some cases, a few 
only of the minute arteries and capillaries were thickened, 
the left ventricle of the heart slightly dilated, whilst the 
kidneys were a little contracted in some of these cases, but 
in others not.^ 

^ See Appendix, Cases 2 and 3. 

^ See cases in the Appendix, Nos. 26 to 35. 



CHRONIC BRIGHT'S DISEASE WITH CONTRACTED KIDNEY. 337 

We have further to state, that this " hyaline-fibroid " 
change was not found in the vessels of healthy persons who 
had been accidentally killed, nor in ordinary phthisis, nor in 
other diseases whose morbid conditions are not allied to the 
cachexia of so-called chronic Bright's disease with contracted 
kidneys.^ 

It is now to be asked. What is the morbid condition 
antecedent to the changes in the minute ai'teries and 
capillaines ? Dr. George Johnson considers that an impure 
state of the blood induces this vascular change. In order 
that we may not do his opinion any injustice, it will be well 
to quote his own words. He says, " In consequence of the 
degeneration of the kidney, the blood is morbidly changed. 
It contains urinary excreta, and it is deficient of some of its 
own normal constituents. It is, therefore, more or less un- 
suited to nourish the tissues, more or less noxious to them. 
The minute arteries throughout the body resist the passage 
of this abnormal blood. The left ventricle, therefore, makes 
an increased effort to drive on the blood. The result of this 
antagonism of forces is that the muscular walls of the 
arteries and those of the left ventricle of the heart become 
simultaneously and in an equal degree hypertrophied. The 
persistent over-action of the muscular tissues, both cardiac 
and arterial, is registered after death in a conspicuous and 
unmistakable hypertrophy.^' 

This theory does not appear to us supported by the facts. 

Dr. George Johnson states that the change in the minute 
arteries is simply hypertrophy of the muscular coat. But 
our examinations show that they are thickened by a " hyaline- 
fibroid formation," and that in fact the muscular coat is often 
variously atrophied. 

Thus Dr. Geoi'ge Johnson regards the changes in the 
heart and arterioles in chronic Bright's disease as a physiolo- 
gical result, due to a morbid change in the blood, whilst our 
observations lead us to regard the cardio-vascular changes 
as throughout a morbid one. 

Further, extreme degeneration of the kidneys, and together 
with this, no doubt, a noxious state of the blood, to which 
Dr. Johnson attributes the vascular change, maybe present, 

^ See particulars of cases given in the Appendix, Nos. 2,^ to 55. 

22 



338 DISEASES OF THE VASCULAE SYSTEM. 

and the vessels may frequently be found healthy. In sup- 
port of this statement we have recorded in the appendix 
cases of large white kidneys, and of scrofulous pyelitis/ in 
which the kidneys were much diseased, and the renal 
changes were chronic, attended with general oedema and 
uraemic symptoms, and the vessels were healthy. Dr. George 
Johnson and other pathologists regard, as we have said, the 
general vascular changes as essentially consecutive to antece- 
dent renal disease, but our inquiries show that these changes 
are, or may be, independent of renal disease, and that the 
renal change in chronic Bright' s disease with contracted 
kidney, when present, is but a part of a general morbid 
condition. 

We ai-e led to conclude that the kidney disease does not 
give rise to the vascular change. Our investigations show 
the disease under the following forms : 

(i) Kidneys often much contracted, heart much hyper- 
trophied, minute arteries and capillaries proportionately 
thickened by " hyaline-fibroid '^ formation." 

(2) Kidneys little contracted, but heart much hyper- 
trophied, minute arteries and capillaries much thickened by 
" hyaline-fibroid " substance.^ 

(3) Kidneys healthy, whilst heart much hypertrophied, and 
minute arteries and capillaries much thickened by " hyaline- 
fibroid " substance.^ 

These facts show that there is a morbid state in which the 
kidneys are contracted, the heart hypertrophied, and the 
minute arteries and capillaries altered by a " hyaline-fibroid " 
formation. Further that the kidney changes are often, but not 
alwaysi, a part and parcel of this morbid state. The absence 
of such lesions of the kidneys proves that they do not con- 
stitute an essential and indispensable part of the general 
process. 

We have already mentioned that the granular contracted 
condition of the kidney is dependent on a " hyaline-fibroid '' 
formation in its arteries and other structures. The same kind 

' See Appendix, Cases 56 to 60. 

^ See Appendix, Cases i, 4, 6, 8, 15, 21. 

' See Appendix, Cases 7, 10, 20. 

* See Appendix, Cases 2, 3, 19 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 339 

of morbid cliange; in fact, occurs in the contracted kidneys as 
occurs in the arteries and capillaries of the pia mater, of the 
skin, of the heart, of the stomach, and other parts. The 
kidney disease would, therefore, seem to he but a part, but 
not an invariable part of the " hyaline-fibroid " change ; but 
as the vascular system was at some part affected with this 
change in all the cases, we regard such vascular change as 
the constant and essential part of this morbid state. 

We have next to consider the pathology of another 
morbid condition which forms part of the state known as 
chronic Bright' s disease. We refer to hypertrophy of the 
left ventricle of the heart unaccompanied by any valvular 
defect or adhesion of the pericardium. 

The morbid appearances of this hypertrophy are so well 
known that it is not requisite for us here to describe them, 
but it is necessary we should state that we have found the 
minute arteries in the walls of the heart much thickened 
by the formation of " hyaline-fibroid " substance already 
described.^ 

Bright, to account for this hypertrophy, says, " The most 
ready explanation appears to be that the quality of the blood 
is altered by the kidney disease. The blood in consequence 
affects the minute and capillary circulation so as to render 
greater action necessary to force it through the vascular 
system.'^ Many pathologists have adopted this explanation. 
Dr. Wilks, however (see ' Guy's Hospital Reports ' for the 
year 1853), has Sliggested that the hypertrophy may be 
dependent on atheromatous changes in the vessels. 

They who adopt the explanation given by Bright, state in 
support of their opinion, that the hypertrophy of the heart 
and the renal disease are so frequently associated together 
as to show that there is some intimate relation between them. 
They further state that this hypertrophy occurs in all forms 
of chronic kidney disease ; and therefore they conclude that 
it is consequent upon diminished excretory power of the 
kidney. 

Dr. Johnson, who supports this opinion, further states 
that physiologists have demonstrated that impure blood cir- 
culates with great difficulty and creates an impediment. 
1 Plate VI, fig. 6. 



340 DISEASES OF THE VASCULAR SYSTEM. 

There is, however, evidence on tlie other hand which 
appears to be strongly opposed to these views. 

Thus the cardiac hypertrophy and the renal disease are no 
doubt frequently associated, as we have said ; but this does 
not prove that there is a relation of cause and effect between 
the two states, for it is evident that both these morbid 
conditions may be dependent on a third more general one. 
Moreover, against this commonly accepted explanation it 
can be shown that in many cases of chronic kidney disease 
the heart is not hypertrophied. Dr. Wilks has mentioned 
to us that in many cases of large white kidney he has found 
the heart free from hypertrophy. Dr. Dickinson states that 
simple hypertrophy of the left ventricle is rarely associated 
with any form of renal disease excepting granular degene- 
ration. 

We have post-mortem records of seventeen cases of large 
white kidneys, and in twelve of them the heart was healthy. 
Dr. Grainger Stewart found in lardaceous disease of the 
kidney that the heart was hypertrophied in only 4 per cent, 
of the cases. In four cases, in which the kidneys were 
almost destroyed by scrofulous pyelitis, we found the heart 
healthy. 

We have particulars of nine cases in which the kidneys were 
very contracted and the heart was free from hypertrophy. 

In these various forms of kidney disease the morbid 
changes were chronic, and it must be supposed that the 
blood was altered. The morbid conditions to which the 
hyperti'ophy is attributed were, therefore, present, but the 
heart, at the same time remaining healthy, shows that these 
renal and blood changes are not sufficient to produce hyper- 
trophy, and indicates that when present it is due to some 
other condition. 

In some of our cases, it is true, the kidneys were large, 
white, and mottled, and the heart was hypertrophied, but 
besides the renal affection the vessels in these cases were 
much diseased by the '' hyaline-fibroid " formation. 

We attribute the hypertrophy to the vascular change. 

Dr. George Johnson explains the occasional absence of 
hypertrophy in cases of chronic Bright's disease by assuming 
that the muscular tissue of the heai't is imperfectly 



CHRONIC BRIGHT'S DISEASE WITH CONTRACTED KIDNEY. 341 

nourished in such cases. In consideriug this suggestion it 
is necessary to bear in mind that if the blood be altered, 
and the circulation in consequence impeded, the left ventricle 
of the heart must contract with greater force than natural 
to overcome the impediment. To accomplish this it must 
acquire increased strength — become hypertrophied ; or it 
would be unable to overcome the obstruction, and the ven- 
tricle then, being unable to empty itself completely, would 
in consequence become dilated. 

Dr. Johnson may in this manner explain disproportionate 
dilatation, but does not explain how a normal-sized heart 
acquires the additional force requisite to overcome the 
supposed obstruction. 

Experience has fully shown that hypertrophy of the left 
ventricle occurs much more frequently with granular con- 
tracted kidneys than with any other form of renal disease ; 
and our observations, supported by the particulars given, 
appear to show that in this foi^m of kidney disease the 
hypertrophy is not induced by the renal affection, but by a 
morbid change in the minute arteries and capillaries. Of 
thirty -four cases in which the kidneys were healthy, excepting 
that they were slightly granular, or in other words ^' coarse/^ 
and contained some cysts, the left ventricle was hyper- 
trophied in eighteen ; and there was no valvular disease or 
pericardial adhesion to account for the hypertrophy. In 
these eighteen cases the hypertrophy would appear to have 
been the older and preceding condition. 

Niemeyer states^ that Bamberger, arguing against the 
view that cardiac hypertrophy is dependent upon the renal 
disease, has shown that it begins in the earlier stages of 
Bright's disease. Observing, therefore, that this cardiac 
hypertrophy occurs not unf requently in the very early period 
of the kidney affection, when the excretory function is not 
greatly altered ; and further observing that the heart in some 
cases is not hypertrophied, when the kidneys are very much 
contracted, and the function of excretion is of necessity 
greatly altered, we also again conclude that the hypertrophy 
is not dependent on the kidney change. 

The following particulars seem, in fine, to indicate that the 
' ' Text-book of Practical Medicine,' vol. i, p. 300. 



342 DISEASES OF THE VASCULAR SYSTEM. 

hypertrophy is induced, as we believe, by the morbid changes 
in the vessels. 

The heart was found (see cases in the Appendix) hyper- 
trophied in all the cases in which the vessels were much and 
generally thickened by the " hyaline-fibroid " change : the 
heart was found slightly hypertrophied where the vessels 
were a little thickened, or a few of them only were thickened 
by this " hyaline-fibroid " material ; the heart was much 
hypertrophied when the vessels were much thickened, and 
there was no kidney or other disease, except this vascular 
change, adequate to account for it. 

Nor is it difficult to explain how the vascular disease gives 
rise to the cardiac hypertrophy. 

The " hyaline-fibroid " material in the walls of the arte- 
rioles must be an impediment to elasticity, and it can be 
experimentally shown that greater force is required to propel 
a fluid continuously through a non-elastic than through an 
elastic tube. The left ventricle, therefore, owing to this 
diminished elasticity of the arterial walls, has of necessity to 
contract with greater force to carry on the circulation. 

It remains to briefly notice a few other morbid conditions 
which form part of the pathological changes known as chronic 
Bright*s disease with contracted kidneys. 

The first is vesicular emphysema. It is well known that 
vesicular emphysema and granular contracted kidneys fre- 
quently co-exist. Of thirty-three cases of persons about 
middle age in which the lungs were emphysematous, the 
kidneys were more or less granular, and contracted in twenty- 
two ; and there were no changes in the lungs to show that 
such emphysema was compensatory. In some of the cases 
the emphysema was great whilst the kidneys were only 
slightly granular ; in other cases the kidneys were much 
contracted whilst the lungs were comparatively little 
diseased, which facts seemingly show that the emphysema 
may precede the kidney contraction, or the kidney disease 
may occur antecedent to the lung disease ; and this is fully 
borne out by clinical experience. We have not as yet had 
an opportunity of examining microscopically the vessels of a 
number of emphysematous lungs associated with contracted 
kidneys, but in a few such lungs we have found the vessels 



CHKONIO BBIGHT's DISEASE WITH CONTRACTED KIDNEY. 343 

surrounded by what seemed to be an unusual quantity of 
fibroid tissue, and it is common to see without the aid of the 
microscope the connective tissue increased around the vessels 
and tubes in these emphysematous lungs. 

With granular contracted kidney we have also found the 
aorta and aortic valves much diseased and the seat of athero- 
matous and sometimes calcareous changes, giving rise to 
dilatation of the aorta, with or without aortic obstruction and 
regurgitation. 

Another morbid condition to be noticed is so-called 
" retinitis albuminurica," which experience has shown to be 
frequently associated with granular contracted kidney. In 
this change of the retina there is sclerosis of the connective 
tissue. There is also sclerosis and fatty degeneration of the 
coats of the blood-vessels, and the vessels have been found 
greatly narrowed and even obliterated. These morbid 
changes in some cases lead to atrophy of the optic disc and 
of the retina.^ The tunica adventitia of the larger retinal 
vessels is often considerably increased in thickness. Mr. 
Bader, in describing these diseased vessels, says,^ " Sclerosis 
is seen in the coats of the blood-vessels, especially of the 
small arteries and capillaries of the I'etina and choroid. 
Their walls are thickened through a homogeneous, strongly 
reflecting, not quite transparent substance." 

From the description given it would seem, therefore, that 
the morbid appeai*ances observed in these retinal vessels 
were similar to those we have observed in the arterioles 
and capillai'ies of the pia mater, kidneys, and other parts. 

The spleen has been found by us in instances of chronic 
Bright's disease diminished in size ; in some cases weighing 
only two or three ounces, and in some no more than one 
ounce and a half : capsule thickened ; on section substance 
tougher than natural, but the most noticeable alteration was 
the increased quantity of fibrous tissue. Under the micro- 
scope the vessels were seen surrounded by a much larger 
quantity of fibroid tissue than usual, and in the outer coats 
of some of the minute arteries " hyaline- fibroid " changes 
were obvious, and similar to such as occur in the arteries of 

' See Mr. Soelberg Wells' ' Treatise on Diseases of the Eye,' p. 358. 
" See ' Guy's Hospital Reports,' 1866. 



344 DISEASES OF THE YASCULAE SYSTEM. 

the kidney and pia mater. In some cases where the kidneys 
were greatly contracted the spleen was very much affected 
in the manner described, but in some cases the spleen was 
much wasted, and the kidneys were little contracted ; in 
other cases the spleen was very little wasted whilst the kidneys 
were very much contracted. 

We also found in many instances of granular kidney 
disease that the convolutions of the brain were much wasted, 
whilst the minute arteries of the pia mater were thickened 
by '' hyaline-fibroid ^' substance. In other cases of contracted 
kidneys, in which the brain was healthy, no " hyaline-fibroid " 
changes were found in the vessels of the pia mater. In a 
few cases the convolutions of the brain were wasted, and the 
vessels of the pia mater were thickened by this " hyaline- 
fibroid " change, whilst the kidney and heart Avere healthy, 
showing the independence of this change of heart or kidney. 

Fibroid changes with atrophy have also been observed by 
Drs. Fenwick and Wilson Fox in the intertubular portions of 
the stomach in chronic Bright^s disease. The arterioles of 
the stomach have been found thickened. We have also 
observed in chronic Bright^ s disease with contracted kidneys 
great fibroid thickening in the walls of the minute arteries 
of the stomach, and fibroid changes in the intertubular parts. 

The clinical history of this morbid state enables us to get 
clearer views of its pathology. Old age is not an entity, but 
it is pre-eminently a condition or set of conditions predis- 
posing to that state which is called chi^onic Bright's disease 
with contracted kidneys. To demonstrate the extent to 
which man at different periods of his life is exposed to gra- 
nular degeneration of the kidney, we have collected from 
post-mortem registers particulars of 336 cases, death being 
due to various diseases. These cases were grouped 
according to the age. The following is the proportion of 
granular degeneration of the kidneys, and the proportion 
of granular to healthy kidneys in each decennial period of 
life. 



CHRONIC bright' S DISEASE WITH CONTRACTED KIDNEY. 345 



From the age of 


The total number 

of deaths from 

all causes. 


The number of 
those cases in which 

the kidneys had 

undergone granular 

degeneration. 


The proportion of granular 

to healthy kidneys in each 

decennial period of life. 


lo — 20 years 

20 — ^0 


44 
69 

84 
82 

39 
13 

S 


I 

2 

10 

31 
28 
12 

4 


I granular kidney in 

44 healthy ones. 
I ditto in 34 ditto. 

I ditto in 8*4 ditto. 

I ditto in 2*6 ditto. 

I ditto in 2'3 ditto. 

I ditto in roS ditto. 

I ditto in 1-2 ditto. 


ao — AO 


4.0 — s , . 


50 — 60 „ 


60 — 70 ,, 


J'O — 80 „ 





It here appears that after the age of forty a large propor- 
tion of persons who die of various diseases have more or less 
granular contraction of the kidneys as shown on the surface of 
these organs ; and it further appears that after forty years of 
life granular degeneration greatly increases as age advances. 

Granular degeneration of the kidneys^ therefore, belongs 
principally to the period of life at or over forty years of age. 

Dr. Dickinson shows that of 308 persons with granular 
kidney only 75 died before forty years , and 233 after forty 
years of age. It is evident, therefore, that chronic Bright's 
disease with granular kidney is allied with the conditions of 
age, and experience shows that it is caused by all those influ- 
ences which are recognised as tending to bring about senile 
changes, whether prematurely or not. 

Children are occasionally the subject of granular con- 
tracted kidney, and there is given in the appendix to this paper 
thie case of a girl, aged 9 years, in whom occurred granular 
and very contracted kidneys, hypertrophied heart, and very 
thick " hyaline-fibroid " arterioles. 

We here mention that occasionally in young subjects not 
over twenty years of age the kidneys may undergo extreme 
contraction and degeneration, and be apparently strictly a 
local affection, and death may occur from the so-called 
ursemic poisoning without any signs of the cardio-vascular 
changes characteristic of chronic Bright's disease with con- 



346 DISEASES OP THE VASCULAR SYSTEM. 

tracted kidneys of a later age. These cases, we believe, 
have another causation. 

It has been shown above, and it is notorious, that many 
organs are diseased in the morbid state known as chronic 
Bright's disease with contracted kidneys; namely, the kidneys 
themselves, the minute arteries and the capillaries, the heart, 
the lungs, the aorta, the brain, the retina, the spleen, the 
stomach, and the skin. 

But these various parts and organs are not constantly 
affected in the same order, nor is there any constant pro- 
portion between them as to the morbid changes each may 
undergo. In some cases all these organs are much diseased, 
and more or less equally so ; in other cases the morbid 
changes are confined to a few and isolated parts. 

In some cases the changes seem to commence in the 
kidneys or in the heart, sometimes in the lungs or in the 
brain, or perhaps in other organs. 

Clinical medicine, especially as followed in private prac- 
tice, enables us often to predict and trace these changes 
onwards until the morbid formation is general. Thus, a 
patient may come under care for headache and other allied 
symptoms, in whom, at a given stage, the renal and cardiac 
functions may be normal ; and as the case goes on, the urine 
first, or the heart first, or the breathing may first give signs 
of further lesion, until, as the malady progresses, that state 
called chronic Bright's disease with contracted kidney may 
be fully produced, as shown by the thickened heart, the pale 
watery urine, the shrunken skin, the troubled brain, and the 
dimmed sight. 

Observing that the pathological change may commence in 
various parts of the body, it might readily be surmised that 
the symptomatic phenomena must be very different in differ- 
ent cases. Experience fully shows that the symptoms are 
very varied in chronic Bright's disease with contracted kid- 
neys ; and we would maintain that its prodromata and the 
prominent symptoms in its course vary with the oi'gan which 
is primarily or predominantly diseased. But whether many 
or few organs are affected, the minute arteries and capillaries 
of the diseased parts have been found by us thickened by 
" hyaline-fibroid " formation. With this '^ hyaline-fibroid " 



CHEONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 347 

formation in the arterioles there is an atrophy of the adjacent 
textures. This appears to be a characteristic of this morbid 
change in whatever organ it occurs. 

It will follow from these facts that we cannot, as some- 
times done, regard the functional disturbances which occur 
in many organs during the course of chronic Bright's disease 
with contracted kidneys as dependent on blood changes only 
or chiefly. For instance, pain in the head, discomfort after 
food, palpitation, dry skin, epistaxis, are we believe due, not 
so much to changes in the blood as to the changes we have 
spoken of in the tissues themselves. 

The conclusions to which we have arrived may be briefly 
summed up as follows : 

1 . There is a diseased state characterised by hyaline-fibroid 
formation in the arterioles and capillaries. 

2. This morbid change is attended with atrophy of the 
adjacent tissues. 

3. It is probable that this morbid change commonly begins 
in the kidney, but there is evidence of its also beginning 
primarily in other organs. 

4. The contraction and atrophy of the kidney are but part 
and parcel of the general morbid change. 

5. The kidneys may be but little if at all affected, whilst 
the morbid change is far advanced in other organs. 

6. This morbid change in the arterioles and capillaries is 
the primary and essential condition of the morbid state called 
chronic Bright's disease with contracted kidney. 

7. The clinical history varies according to the organs 
primarily and chiefly affected. 

8. In the present state of our knowledge we cannot refer 
the vascular changes to an antecedent change in the blood 
due to defective renal excretion. 

9. The kidneys may undergo extreme degenerative changes 
without being attended by the cardio-vascular and other 
lesions characteristic of the condition known as chronic 
Bright's disease. 

10. The morbid state under discussion is allied with the 
conditions of old age, and its area may be said hypothetically 
to correspond to the " area vasculosa." 



348 



DISEASES OF THE VASCULAR SYSTEM. 



II. The changes^ though allied with senile alterations, 
are probably due to distinct causes not yet ascertained. 

Should it be considered necessary to distinguish this 
morbid state by any special term, we venture to suggest for 
that purpose the name " arterio-capillary fibrosis." 



APPENDIX. 



Case i. — William L — ,^ set. 43, who died January ist, 187 1 . The autopsy 
showed the kidneys were very granular and contracted. They were mottled 
on their surfaces, and in their cortical parts there was a quantity of yellowish- 
gi'ey matter, similar to what is seen in acute nephritis. The left ventricle 
of the heart was dilated and its wall much hypertrophied. The heart weighed 
seventeen and a half ounces. There was no valvular disease. Many of the 
arterioles of the pia mater were much thickened, and the measurements were 
as follows : 



The relative width of 
the vessels. 


Of the channel. 


Of the sides or walls 
of the vessel. 


II 


4 


7 


15 


5 


10 


17 


6 


II 


TO 


2 


8 


15 

28 


8 


10 
13 


14 

16 


5 
6 


9 
10 


30 


14 


26 



The muscular layers of the arterioles were not increased. The thickening 
was due to the outer layer of the vessel being increased in size. This part 
had a very fine fibroid appearance. In some parts it ajipeared to be made up 
of homogeneous-looking matter. Many of the arterioles were in this manner 
diseased. 

Case 2. — Sarah S — , set. 63, who died January 25th, 1871. Autopsy showed 
that the cause of death was rupture of left ventricle of heart. The heart 
weighed fifteen ounces, and its left ventricle was dilated and hypertrophied. 
The kidneys weighed fifteen ounces ; their surface was almost smooth ; there 
was no decided granular change ; the cortical parts were not contracted ; the 
kidney substance was red, and showed venous congestion only. Very many 
of the arterioles were much thickened, and this was caused by a quantity of 
hyaline- fibroid substance outside the muscular layer, and the tunica intima in 
some of the vessels also was thicker than natural. 

' Further details of this patient and the cases following may be seen in 
the post-mortem registers of the London Hospital. 



CHRONIC BREGHT's DISEASE WITH CONTRACTED KIDNEY. 349 



relative width of • 


ressel. 


Of channel. 


Of walls. 


13 




6 


10 


10 




3 


8 


16 




4 


12 


12 




3 


9 



The muscular nuclei were very imperfect in some of the arterioles. In some 
parts they were normal ; in others they were replaced by large clear granules, 
or they were entirely absent. 

Case 3. — James D — , set. 77, died of peritonitis following strangulated 
hernia. The autopsy showed that the left ventricle of the heart was dilated 
and hy|)ertrophied. Its valves were healthy excepting a little atheroma in 
the mitral. The kidneys were venously congested ; otherwise they were 
healthy. The walls of many of the arterioles were much thickened, and this 
was due to a granular fibroid growth outside the muscular tissue. The 
outermost part of the wall of the arterioles had a distinct fibroid appearance. 
Within this there was a homogeneous finely granular substance. Lying 
amongst this graniilar material were numbers of short, imperfectly developed 
fibres and oat-shaped nuclei. In some arterioles the muscular layer was well 
defined. 

Of walls. 

16 

8 

14 

12 

17 
20 

And in some of the arterioles the nuclei were faintly stained with carmine ; 
in many other parts the muscular nuclei could not be seen, or they were very 
irregular in shape. The tunica intima had a coarse fibroid appearance, and 
in other arterioles a granular appearance. In some of the arterioles it was 
thicker than natural. Many of the vessels were in this manner affected. 

Case 4. — James R — , tet. 58, died of suppurative pericarditis apparently 
pysemic, July 25th, 1871. The left ventricle of the heart was much hyper- 
trophied, and the aortic and mitral valves were normal. The kidneys were 
small, their surfaces markedly granular, and they contained cysts. 

Of walls. 
12 
16 
14 
15 
20 

Some of the arterioles were much thickened, others were not. The 
thickening was not so great as is observed in some cases. The outer and 
inner coats of the thickened arterioles contained a quantity of hyaline 



Relative width of vessel. 


Of channel. 


24 


8 


12 


4 


22 


8 


21- 


9 


29 


12 


38 


18 



Relative width of 


vessel. 


Of channel. 


20 




8 


28 




12 


22 




8 


25 




10 


40 




20 



350 



DISEASES OF THE VASCULAR SYSTEM. 



matter, and to this change the increased size of the arteriole wall was due. 
The muscular nuclei were in parts shrivelled and very much wasted. The 
most marked disease was external to the muscular layer. The walls of the 
thickened capillary arterioles had a homogeneous granular appearance. A 
number of fat-gi-anules were aggregated in some vessels. 

Case 5. — James S — , set. 39, died suddenly, apparently in consequence of 
dilatation of the left ventricle, on 15th May, 1871. Heart weighed 
I lb. 14I oz. The left ventricle was very much dilated and its wall hyper- 
trophied. The left auricle was also much dilated. Valves were normal. 
The spleen was small. The kidneys were faintly granular and much 
puckered on their surfaces ; on section they appeared congested, otherwise 
the cortical and medullary parts were natural. Some of the arterioles were 
much thickened, but this change was mostly seen in the very minute ones. 



Relative widta 


of- 


vessel. 


Of channel. 


Of 


■ walls. 


22 






9 




14 


23 






9 




14 


31 






14 




17 


30 






10 




20 


20 






8 




12 


20 






6 




14 


30 






12 




18 


33 






15 




18 



The layer outside the muscular nuclei was much thicker than natural, and 
it had a distinct hyaline-fibroid appearance. The muscular nuclei were very 
defined and normal in some parts of the arterial wall, and absent in others. 
The capillaiy arterioles were also thickened, and they had a fine gi-anular 
appearance. 

Case 6. — John H — , set. about 45. He was brought into the London 
Hospital dead on May 20th, 1871, The left ventricle of the heart was dilated 
and hypertrophied. The aortic valves were calcareous and incompetent. 
The lungs were emphysematous. The spleen was small. The brain was 
wasted. The kidneys were moderate in size, and they were very granular, 
and contained numbers of cysts. The cortical parts were smaller than 
natural. Many of the arterioles of the pia mater were much thickened. 
External to their muscular nuclei there was a hyaline-fibroid-looking sub- 
stance, which made the external coat much thicker than normal. Many of 
the large capillaries were also very much thickened, and their walls had a 
granular or homogeneous appearance. The tunica intima of some of the 
arterioles was also thicker than natural. 



live width of 


vessel. 


Of channel. 


Of walls. 


28 




9 


19 


27 




7 


13 


25 




8 


17 


21 




8 


13 


21 




9 


12 



CHRONIC BEIGHT's DISEASE WITH CONTRACTED KIDNEY. 351 



ielative width of 


vessel. 


Of channel. 


Of walls 


33 




10 


23 


20 




7 


13 


13 




5 


8 


23 




9 


14 


II 




3 


8 


25 




9 


16 


25 




9 


16 


14 




4 


10 


10 




2 


8 


30 




9 


21 



Case 7. — Edward L — , tet. 42, died o£ erysipelas secondary to a scalp 
wound. Autopsy December 28tb, 1870. The lungs were very emphyse- 
matous, more or less, throughout, and there was capillary bronchitis. Many 
of the minute bronchial tubes were filled with pus. The left ventricle of 
the heart was dilated and somewhat hypertrophied, also the right ventricle. 
The spleen and liver were natural ; the kidneys were faintly granular, other- 
wise healthy. 

Many of the arterioles and capillaries of the pia mater were much 
thickened. In the coats of the arterioles external to the muscular nuclei a 
quantity of hyaline -fibroid substance was seen, and to this change the thick- 
ening was due. 

The nuclei of the muscular tissues were very indistinct in some parts and 
absent in others. The walls of the capillaries were thickened by the forma- 
tion of a granular or homogeneous substance. 



The relative width of vessel. 


Of its channel. 


Of its walls 


7 


2 


5 


10 


3 


7 


9 


3 


6 


II 


3 


8 


13 


3 


10 


12 


5 


7 


34 


12 


22 


32 


12 


20 


44 


18 


26 


42 


16 


26 



Case 8. — Emma C — , set. 9 years. The kidneys were very much smaller 
than natural, especially the left; one weighed 2 oz., the other ij oz. The 
kidneys in consequence of being greatly contracted were much out of shape ; 
their cortical parts were much reduced in size ; their surfaces were very 
irregular and puckered, not finely granular. The heart's left ventricle was 
dilated and hypertrophied ; its valves were healthy. The spleen was small and 
tough. Some of the arterioles of the pia mater were veiy much thicker than 
natural, owing to the layer outside the muscular layer being much increased. 



352 



DISEASES OF THE VASCULAR SYSTEM. 



vidth of vessel. 


Of channel. 


Of walls 


30 


12 


18 


0- 


12 


20 


S6 


14 


22 


34 


14 


20 


36 


10 


26 


20 


6 


14 


20 


6 


14 


18 


6 


12 


20 


8 


12 


20 


8 


12 


18 


6 


12 


20 


8 


12 


18 


8 


10 


iS 


5 


13 


14 


6 


8 


20 


8 


12 



The layer external to tlie muscular nuclei was thicker than the tunica 
intima and tunica media taken together, and in the larger arterioles it had 
a fine fibroid or hyaliue-fibroicl appearance. The thickening was most marked 
in the capillary arterioles or larger capillaries, and this change was due to 
the formation of granular hyaline substance in the walls of these vessels. The 
arterioles of the kidneys were much thickened by fibroid changes. 

Case 9. — Margaret B — , set. 68, died of acute meningitis following iridec- 
tomy. The kidneys were granular and cystic, but not apparently contracted. 
The left ventricle of the heart was slightly dilated and slightly hypertro- 
phied. Some of the arterioles of the pia mater were much thickened, and 
their outer coats were much increased in size. This portion of the vessel 
was thickened by the formation of a hyaline-fibroid substance. 

The relative width of the vessels. Of the channel. Of the walls. 



35 
52 
25 
38 
21 

27 
15 
22 

25 



14 

19 

7 

10 

5 

6 
6 

5 

8 



33 
18 
28 
16 
21 
9 
17 
17 



Many of the arterioles appeared to be healthy. The outer coats of the 
larger arterioles were thickened by a fine fibroid substance. The thickened 
capillary arterioles had a homogeneous appearance. 



Case 10. — Thomas B — , set. 69, died of senile gangrene, May 4th, 1871. 
The kidneys were granular and cystic, but not contracted. The heart 



CHEONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 353 

weighed i6| oz., the left ventricle was dilated and its wall hypertrophied ; 
there was no valvular disease. The lungs were emphysematous and the 
brain atrophied. 

The relative widtli of the vessels. Of the chantiel. Of the wall. 

29 ... 12 ... 17 

30 ... 14 ... 16 

21 ... 9 ... 12 
28 ... 16 ... 12 

22 ... 8 ... 14 
32 ... 13 ... 19 
38 ... 16 ... 22 
30 ... 10 ... 12 
20 ... 6 ... 14 
42 ... 20 ... 20 

26 ... 8 ... 18 

24 ... 8 ... 16 

The outer coats of the arterioles were much increased in size, and the 
vessels in consequence were thickened. 

Almost all the arterioles of the pia mater were thickened more or less, but 
the amount of thickening varied very much in the different vessels : in some 
it was little, so that it did not much increase the diameter of the vessels ; in 
others it was very great, and it was due to hyaline-fibroid changes in the walls 
of the arterioles external to their muscular coats. 

The tunica intima of some of the arterioles was also increased in size. The 
walls of the minute capillary arterioles were very much thickened, and they 
had a molecular hyaline appearance. The muscular nuclei of the arterioles 
were stained in parts, and they appeared to be normal ; in other parts they 
were wasted and indistinct. A number of fat-globules were aggregated 
together in the walls of manv of the minute vessels. 



Case ii. — Frederick B — , jet. 31. The kidneys weighed 105 oz. ; they 
were markedly granular, and the cortex was somewhat wasted, and they con- 
tained several cysts. The left ventricle of heart was hypertrophied and 
dilated ; its valves were healthy ; its right side was also dilated. The spleen 
was large and dark. 



Lness 


of vessel. 


Of channel. 


Ofwal 


23 




7 


16 


30 




8 


22 


18 




6 


12 


25 




8 


17 


29 




7 


22 


21 




6 


15 


26 




9 


17 


28 




9 


19 


16 




6 


II 



23 



354 DISEASES OF THE VASCULAR SYSTEM. 

The cerebral arteries were atheromatous, and the brain was wasted ; many 
of the arterioles of the pia mater were much thickened by hyaline-fibroid 
substance outside the muscular nuclei. 

Case 12. — Sarah R — , set. 32, died August 24th, 1871. The kidneys were 
granular and contracted. The post-mortem appearances have not been 
described in the register. 



The relative width of vessels. 


Of channel. 


Of walls. 


21 


8 


13 


22 


8 


14 


23 


9 


14 


24 


6 


14 


20 


8 


12 


20 


7 


13 


31 


9 


22 


27 


8 


19 


23 


7 


16 


21 


8 


13 



The arterioles were very much thickened, and their coats outside the mus- 
cular layer were much increased in size ; some of the arterioles were appa- 
rently unaffected, but many were thickened. The layer outside the muscular 
nuclei of the thickened arterioles was seen to consist of a hyaline-fibroid 
substance, and the thickening was caused by this new material. In this new 
formation a number of minute nuclei were seen. 

Case 13. — James P — , set. 49. The kidneys were not granulai*, but large 
and mottled, and their appearance indicated that they had been recently the 
seat of acute nephritis. The left ventricle of the heart was dilated. The 
liver was in the condition known as incipient cirrhosis. 

Many of the minute arteries of the pia mater were much thickened, and 
the layer outside the muscular tissue was increased ; it was much thicker 
than the middle and inner coat taken altogether, and this thickening was 
due to a hyaline- fibroid substance. In some of the arterioles the muscular 
nuclei were very indistinct, and they were replaced by fat-granules ; in 
others they were very distinct. The arterioles were not all equally involved. 
Some of the arterioles of the left ventricle of the heart were much thickened 
by fibroid formation, also the arterioles of the kidneys and skin. In the 
capillary walls fat-granules were aggregated in greater numbers. The rela- 
tive size of the different parts of the vessels are given below. 

Relative width of vessel. Of channel. Of walls. 

15 ... 5 ... 10 

13 ... 5 ••• 8 

15 ... 6 ... 9 

12 ... 5 ... 7 

30 ... 10 ... 20 

19 ... 7 ... 12 

25 ... 10 ... 15 



CHRONIC BRIGHT S DISEASE WITH CONTRACTED KIDNEY. 355 



Relative width of 


vessel. 


Of channel. 


Of walls 


28 




12 


20 


15 




5 


10 


9 




3 


6 



The outlines of nearly all the minute arteries were unusually clearly 
defined. The channels of the thickened arteries were not appreciably 
encroached upon. 

Case 14. — George T — , set. 67, died of cerebral haemorrhage. We regret 
that we could not obtain detailed particulars of this case. 

Many of the arterioles were very much thickened outside the muscular 
layer by a hyaline-fibroid substance. Amongst this new material were a 
number of indistinct corpuscles or nuclei which at first sight looked like 
muscular^tissue, but the muscular layer was observed to be entirely distinct 
from those imperfectly formed elementary bodies. 

The relative width of vessel. Of channel. Of walls. 

24 ... 9 ... 13 

22 ... 7 ... 15 

57 ••• 21 ... 36 

38 ... 9 ... 30 

57 - 21 ... 38 

Case 15. — Charlotte A — , set. 55. The kidneys were coarse on the surface ; 
they were also wasted. They weighed 7 J oz. Heart weighed i lb. if oz. ; 
its left ventricle was dilated and hypertrophied. Many of the arterioles of 
the pia mater were very much thickened, and the coat outside the muscular 
layer was much increased by hyaline-fibroid formation. The new tissues in 
some of the thickened vessels were coarsely fibroid. The muscular nuclei 
were much altered in some of the arterioles. 

The relative width of the vessel. Of the channel 
36 
32 
28 
36 

Case 16. — James B — , set. 48. Cause of death was dilatation of the left 
ventricle. The kidneys weighed I2-| oz. ; they were very granular, and 
contained a few cysts. The cortical parts were very little contracted. Liver 
capsule was thickened. Heart weighed i lb. 8 oz., and the left ventricle 
was much dilated and hypertrophied. Very many of the arterioles of the 
pia mater were very much thickened, and their outer coats were much in- 
creased by the formation of hyaline-fibroid substance. The tunica intima in 
some arterioles was also much increased in size by the formation of hyaline- 
fibroid substance, and the larger capillaries were thickened by homogeneous 
or granular material. 

In some of the arterioles the new tissue was veiy distinctly fibroid, and 
the hyaline appearance was not well marked. The muscular nuclei were 



channel. 


Of the walls 


16 


20 


12 


20 


I I 


17 


16 


20 



356 DISEASES OF THE VASCULAR SYSTEM. 

wasted in some parts of these vessels, and the muscuhir layer seemed thicker 
than natural in other parts. 

The relative width of the vessels. Of the channel. Of the walls 

32 ... II ... 22 

33 ■■■ 8 • • 22 

33 ••• 8 ... 25 

Case 17. — A man, jet. 64, had a cyst in the brain; died in the White- 
chapel Workhouse. The kidneys were markedly granular, but not much 
contracted. The left ventricle was hypertrophied and dilated. For these 
particulars we are indebted to Dr. Ilott, the Resident Medical Officer of the 
Whitechapel Workhouse. 

The arterioles in the pia mater were very much thickened, and the coat 
outside the muscular layer of these vessels was greatly increased by fibroid 
changes. This condition was very well marked in many of the arterioles, 
and the muscular nuclei were very distinct and clearly defined in some, and 
a good deal wasted in others. 



The relative width of 


vessels. 


Of channel. 


Of 


walls 


18 




6 




12 


36 




13 




23 


36 




14 




22 


42 




15 




27 


31 




9 




22 


36 




14 




22 


35 




II 




24 


30 




8 




22 


26 




8 




18 



Case 18. — James B — , a?t. 50, died of acute nephritis; the kidnej-s were 
large and their surfaces smooth ; were very much congested and mottled ; 
some grey material was scattered amongst the highly congested tissue. The 
cortical portions had a similar appearance, and they were increased in size. 
The kidneys had the morbid appearances commonly seen in an early stage of 
acute nephritis. Heart : the left ventricle was much dilated and hyper- 
trophied, and its valves were healthy. Many of the arterioles of the pia 
mater, especially the smaller ones, were very much thickened, and their 
outer coats increased in size. Some of the vessels were not uniformly 
thickened, but in parts only. The muscular nuclei were in some of the 
arterioles very indistinct and in other parts absent ; they were replaced by a 
granular substance ; outside the muscular layer there was a quantity of 
hyaline-granular or hyaline-fibroid substance which caused the thickening. 
The walls of the larger capillaries were infiltrated with a similar hyaline- 
granular substance ; many capillaries were in this manner diseased. 



Relative width of vessel. 


Of channel. 


Of walls. 


19 


6 


13 


20 


7 


13 


32 


II 


22 



CHRONIC BKTGHT's DISEASE WITH CONTRACTED KIDNEY. 357 



;ive width of 


vessel. 


Of channel. 


Of walls. 


21 


... 


8 


13 


27 




9 


18 


40 




13 


27 



Case 19. — Samuel C — , set. 62, died suddenly in a comatose condition. 
The brain was considerably wasted. The cerebral arteries were very athero- 
matous. Spleen weighed 4 oz. ; liver 2 lb. 11 oz. The kidneys weighed 
'8 oz., and with the exception of the capsule being adherent they were normal. 
These organs were very carefully examined by Dr. Hughlings Jackson and 
Dr. Sutton, and they both agreed that they presented no other signs o£ 
disease. The heart weighed 15 oz. ; it was much increased in size, owing to 
dilatation and hypertrophy of the left ventricle. Its valves were healthy. 
Lungs were emphysematous. Many of the arterioles of the pia mater were 
very much thickened, the layer outside their muscular tissue was much in- 
creased in size. This was diie to a fine granular transparent substance. 
This new material was seen between the muscular nuclei and the coarser 
fibres of the tunica adventitia. The larger capillaries were also much 
thickened, and their walls had a granular or homogeneous appearance. 



idth of vessel. 


Of channel. 


Of wall! 


40 


16 


24 


42 


14 


28 


42 


14 


28 


60 


28 


32 


54 


24 


30 


.54 


22 


32 


.50 


20 


30 


28 


10 


18 


30 


10 


20 


30 


12 


18 


34 


14 


20 


40 


16 


24 


40 


16 


24 


26 


8 


18 


28 


12 


16 


30 


10 


20 


32 


12 


20 


22 


8 


14 


22 


8 


14 


24 


8 


16 



Case 20. — William H — , set. 51. There was softening of the cerebellum. 
The kidneys weighed iif oz. They were granular, and they contained the 
remains of the two embolic blocks, otherwise they were healthy. The heart 
weighed i lb. 9 oz. All its cavities were dilated and the ventricular walls 
much hypertrophied ; some vegetations on the aortic valves. 

Many arterioles were very much thickened, and the layer outside the 
muscular nuclei was much increased in size. In this part a quantity of 



358 DISEASES OF THE VASCULAR. SYSTEM. 

hyaline-granular and finely marked fibroid substance was seen. The walls of 
some o£ the arterioles were unequally thickened. The tunica intima was 
also thicker than natural, owing to the formation of a fine fibroid tissue. 
The muscle of the arterioles was much wasted in some spots, and replaced 
by bodies which looked like large fat-granules. The larger capillaries were 
very much thickened, and their walls had a fine granular appearance. 



width of vessel. 


Of channel. 


Of walls 


24 


8 


16 


28 


10 


18 


36 


16 


20 


32 


12 


20 


72 


18 


54 


72 


16 


56 


20 


8 


12 


20 


8 


12 


24 


8 


14 


38 


16 


22 


40 


16 


24 


44 


18 


26 


44 


16 


28 


32 


12 


20 


30 


12 


20 


30 


10 


20 



Case 21. — William S — , set. 56, died on November 24th, 1871. 

Autopsy showed that the heart was enlarged; it weighed 19 oz. The 
right ventricle was much dilated, and the left ventricle was also dilated and 
hypertrophied. The lungs were emphysematous. Liver was in an early 
condition of cirrhosis. Kidneys weighed 1 1 oz. ; their surfaces were granular. 
One kidney was much contracted, the other rather larger than natural. 
There were indications also of recent acute nephritis. 

Microscopical examination of the pia mater showed that many of the 
arterioles were healthy, excepting that their outline was much more sharply 
defined than natural. Some of the arterioles were much thickened, and this 
was due to the increased size of their outer coat. The new formation in this 
part had a very fine hyaline-fibroid appearance. Some of the larger capil- 
laries were very much thickened, and their walls were granular and translu- 
cent. A quantity of fat-globules were aggregated together in the coats of 
the minute vessels. 



Diameter of tlio 


vessel. 


Oftl 


e ch; 


nnel. 


Of the walls. 


16 






5 




II 


22 






7 




16 


40 






15 




25 


23 






10 




13 


32 






17 




I.'S 


36 






20 




16 


26 






13 




13 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 359 

Case 22, a patient under the care of Dr. Hughlings Jackson, died in the 
Epileptic Hospital in November, 1871. 

We are indebted to Dr. Jackson for kindly afBording us the opportunity 
of examining the pia mater and kidneys. The left ventricle of the heart 
was much hypertrophied. The kidneys were very granular, and their cor- 
tical parts were very much contracted. 

Many of the arterioles of the pia mater and kidneys were very much 
thickened. The layer outside the muscular nuclei was much thicker than 
natural, and this was due to the formation of hyaline-fibroid substance. The 
muscular tissue was not appreciably increased, but it was wasted in parts, and 
in some spots the muscular nuclei were entirely absent. The outer layer of 
the larger vessels was also thickened by a similar fibroid change. 

Diameter of the vessel. Of the channel. Of the walls. 



32 


12 


20 


28 


11 


17 


22 


8 


14 


26 


9 


17 


35 


14 


19 


48 


25 


23 


52 


25 


27 


33 


10 


23 


27 


10 


17 


24 


9 


15 


22 


8 


14 



Case 23. — Edward S — , set. 46. Autopsy February 22nd, 1872. The 
brain was healthy; lungs were cedematous. Heart weighed i lb. I5f oz. ; 
its left ventricle was very much dilated, and its wall much hypertrophied ; 
valves and orifices healthy. Eight ventricle and auricle were also dilated. 
Liver and spleen presented no noticeable change. Kidneys — their surfaces 
were granular and mottled. A quantity of greyish material was seen amidst 
highly congested tissue. The appearances were such as are usually con- 
sidered to indicate acute nephritis. The cortical parts were very much 
contracted, so that the tubes in part almost reached the surface of the 
kidney. The cortex also mottled like the surface. The arterioles of the 
pia mater were healthy. They were very carefully examined, and they 
presented none of the hyaline-fibroid changes seen in other cases, nor were 
there any indications of thickening. The arterioles of the skin, stomach, 
and kidneys, were greatly thickened by the formation of hyaline-fibroid 
material. 

Case 24. — John J — , set. 37. Autopsy April 22nd, 1872. The lungs 
were congested and cedematous. There was evidence of recent pericarditis. 
The heart weighed i lb. 25 oz. ; its left ventricle was much hypertrophied ; 
its valves and orifices were healthy. The right ventricle was also greatly 
dilated. The capsule of the liver was slightly thickened; this organ was 
otherwise healthy. Spleen — its capsule was also slightly thickened, but its 



360 DISEASES OF THE VASCULAR SYSTEM. 

substance apparently healthy. Stomach was healthy. Kidneys were very 
granular, mottled on their surface, and greyish material scattered here and 
there, the latter apparently the product of acute nephritis. The cortical 
parts were much contracted. The arterioles of the skin were veiy much 
thickened by fibroid material. This new formation was seen outside the 
muscular layer. The fibroid formation had a coarse fibre-like appearance. 
The arterioles of the retina were also thickened by the formation of a 
hyaline fibroid material. 

Case 25. — Elizabeth L — , set. 42. Autopsy April 2nd, 1872. A very 
large blood-clot was found in the left hemisphere, outside the optic thalamus. 
There was a small clot in the pons Varolii, and a cyst in the right hemi- 
sphere. The left ventricle of the heart was considerably hypertrophied. 
Heart's valves and orifices healthy. The lungs, liver, and spleen were 
natural. The kidneys were very granular, small, and their cortex was much 
contracted. Many of the minute arterioles were thickened, some of them 
very much so by hyaline- fibroid substance outside the muscular layers. In 
a great many of the arterioles and capillaries a quantity of fat-granules 
were aggregated together. 

Besides the above cases, in which the arterioles were very 
much thickened, we examined ten other cases in which some 
of the arterioles of the pia mater were thickened, though to 
a much less extent. In these cases the morbid condition 
appeared to be in a much earlier stage, but the histological 
changes were similar in kind though less in extent to those 
observed in the very thick vessels. 

Case 26. — Elizabeth E — , set. 44. The kidneys weighed 8 oz. ; they were 
slightly granular and contained cysts. The lungs were extremely emphyse- 
matous. The brain was atrophied. The heart weighed io| oz. ; its left 
ventricle appeared to be slightly dilated, and there was atheromatous disease 
(if the aortic valves. The outer layers of a few of the arterioles were thicker 
than natural owing to the formation of a hyaline- fibroid tissue, and this new 
formation was seen outside the muscular nuclei. 



The width of the 


arterioles. 


Of the channel. 


Of the 


sides or walls 


30 




18 




12 


30 




19 




II 


45 




28 




15 


22 




10 




12 


A 25 




10 




15 


B22 




9 




14 


24 




16 


.. 


8 


14 




8 




6 



Case 27. — John S — , aet. 74, died of broncho-pleuro-pneumonia. The lungs 
were emphysematous; the liver atrophied. The spleen was also atrophied ; 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 361 

it weighed only 4I oz. The kidneys were slightly granular, and not con- 
tracted ; they weighed 15 oz. The increased weight was apparently due to 
venous congestion. The heart weighed 15 oz. There was no valvular 
disease, and the left ventricle was dilated and somewhat hypertrophied. A 
few of the arterioles were markedly thickened. 



The width of the arterioles. 


Of the chanuel. 


Of the 


sides or walls. 


A 10 


3 




7 


B 13 


5 




8 


C 57 


24 




33 


D 32 


10 




22 


12 


6 




6 


14 


6 




8 


10 


4 




6 



The increased size of the arterial walls was due to the formation of a 
hyaline-fibroid tissue in the outer coat of the vessels. There was no evidence 
of muscular hypertrophy. 

Case 28. — A man, xi. 60, died in the London Hospital August 28th, 
1 87 1, of epithelioma of the oesophagus. The heart was moderately dilated. 
Some of the arterioles of the pia mater were thickened by the formation of 
fine fibroid-looking tissue in their outer coats. There was no muscular 
hypertrophy ; the walls of some of these thickened vessels were very irre- 
gular in size. The measurements are given, and the letters A B C 1) E P 
indicate the thickened ones. By far the greater number of the arterioles 
were not thickened. A large number of fat-granules were aggregated in the 
walls of the minute vessels. 

The width of the arterioles. 



A 


31 


B 


32 


C 


26 


D 


25 


E 


20 


F 


28 




35 




19 




19 




40 



Of the channel. 


Of the sides or walls. 


II 


20 


II 


23 


7 


19 


15 


20 


8 


12 


10 


18 


18 


17 


18 


II 


18 


II 


21 


19 


12 


10 


14 


16 



Case 29. — James C — , set. 74, died in the London Hospital with disease 
of the knee-joint November 25th, 1871. The autopsy showed that the 
heart's muscle had undergone fatty degeneration. The condition of its 
cavities is not mentioned in the post-mortem record. The lungs were 
emphysematous ; the arteries were very atheromatous ; the renal capsules 
were adherent, and the kidneys contained cysts ; the outer coats of some of 



362 DISEASES OF THE VASCULAR SYSTEM. 

the arterioles were thickened by the formation of some coarse-looking fibroid 
tissue. The measurements of the thickened ones were as follows : 



Width of the arteriole. 


Of tlie channel. 


Of the sides or walla 


19 


7 


12 


13 


5 


8 


17 


7 


10 



Case 30. — George G — , set, 57, died of acute peritonitis following hernia. 
Autopsy July 12th, 1871. The spleen was atrophied ; it weighed 3^ oz. only. 
Liver atrophied, and weighed 2 lbs. 1 1 oz. ; the kidneys weighed 11 oz. ; they 
were slightly granular, otherwise natural ; the heart weighed 12 oz. A few 
of the arterioles were slightly thickened in their outer coats by the formation 
of a fine hyaline-fibroid tissue; by far the majority of the arterioles were not 
thickened. The measurements and letters A B show the proportions of the 
slightly thickened arterioles ; the remaining measurements show no evidence 
of thickening. 

Width of the arteriole. 

B46 
31 

47 
38 
51 
38 
18 
10 

14 
II 

Case 31. — A man, aged about 45, died of acute pneumonia. The kidneys 
were healthy, and the heart weighed 14 oz. Its left ventricle was slightly 
dilated. None of the arterioles were greatly thickened, but the walls of 
some of them were more sharply defined than natural, and the outer layers 
of a few arterioles were somewhat thickened, and had a fine fibroid appear- 
ance. The muscular nuclei were indistinct in many of the vessels. The 
measurements given show the amount of thickenins: : 



Of its channel. 


Of its sides or walls 


16 


23 


21 


25 


15 


16 


27 


20 


22 


16 


28 


23 


27 


II 


9 


9 


5 


5 


7 


7 


6 


5 



Width of the vessel. 


Of its channel. 


Of its sides or walls 


42 


19 


23 


42 


20 


22 



Case 32. — A female died after removal of cancer in the breast, January 
20th, 1872. The kidneys were granular, but not markedly wasted. Peri- 
cardium was adherent. The left ventricle of the heart appeared somewhat 
dilated ; its valves and orifices were healthy ; its muscle was very fatty. 
The arterioles of the pia mater were very sharply defined, and their outer 
layers seemed thickened by the formation of a fine fibroid tissue. 



CHRONIC BRIGHt's DISEASE WITH CONTRACTED KIDNEY. 363 

Case 33. — Robert B — died December 2nd, 1871. The autopsy showed 
vesicular emphysema. The heart was normal. The kidneys were large and 
mottled ; they presented the appearances seen in a somewhat early stage o£ 
acute Bright's disease. The vessels were for the most part healthy; the 
only noticeable change was that the outlines o£ the arterioles were more 
sharply and clearly defined than natural. Only one arteriole was found 
with its outer layer thicker than natural, and it had a fine hyaline-fibroid 
appearance, and only one capillary arteriole was observed much thickened ; 
its wall had a granular homogeneous appearance. The measurements indi- 
cated by the letter A show the proportions of the thickened vessel ; the 
remaining measurements do not indicate any thickening. 



Width of the 


vessel. 


Of 


its chaunel. 


Of the 


sides or walls. 


A 22 






8 




16 


32 






10 




12 


34 






20 




14 


42 






25 




17 


44 






26 




18 



C.iSE 34. — William W — , set. 63, died of cerebral hsemorrhage November 
nth, 1871. The heart weighed 13 oz. ; its left ventricle was somewhat 
dilated. There was no valvular disease. The kidneys weighed io4 oz., and 
they were healthy. The spleen was wasted. The outer layers of some of 
the arterioles were slightly thickened by the formation of a fine fibroid 
tissue. This was most distinctly seen outside the muscular nuclei. In no 
place were the arterioles greatly thickened. The measurements given show 
the thickening was not sri'eat. 



V'idth of the arteriole. 


Of the channel. 


Of the sides or walls. 


24 


10 


14 


16 


8 


8 


28 


12 


16 


36 


14 


22 



Case 35. — Chas. M — , set. 49. Autopsy December 9th, 187 1 ; cause of 
death contusion of brain, the result of injury. Heart weighed 14 oz. 
Vegetations were seen on the aortic valves. Liver was congested, and 
weighed 3 lbs. 2i oz. Kidneys weighed 9 oz. ; their surfaces were slightly 
gi'anular and cystic ; cortical substance small. Some of the arterioles were 
thickened in their outer layers by the formation of a fibroid substance. The 
measurements given show the degree of thickening. 



Width of tlie vessel. 


Of its chaunel. 


Of its sides or walls. 


46 


16 


30 


37 


18 


19 


72 


26 


56 



5G4 



DISEASES OF THE VASCULAR SYSTEM. 



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CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 365 



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DISEASES OF THE VASCULAR SYSTEM. 



Measurements of the arterioles, 

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44 

27 

29 
44 
16 

42 
40 
40 


Condition of arterioles 


There were no indications of thick- 
ening in the vessels of the pia 
mater; the nuclei of the mus- 
cular fibres almost touched the 
outer edge of the arterioles, and 
there was in consequence very 
little appearance of tunica ad- 
ventitia; there were no aggre- 
gations of fat-granules. 

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was no evidence of thickening; 
the muscular nuclei were seen 
close to the outer edges of the 
walls of these vessels ; there were 
no large aggregations of fat- 
granules. 

The arterioles were healthy; the 
muscular nuclei were very well 
stained, and they were seen lying 
close to the outer edge of these 
vessels; there were no aggrega- 
tions of fat-granules. 


c 


Autopsy showed acute endocar- 
ditis; left ventricle and muscle 
of heart dilated ; disease of the 
aortic valves; acute pneumonia 
and pleurisy; morbid changes 
in the kidneys, indicating acute 
nephritis. 

Autopsy showed broncho-pneumo- 
nic phthisis. 

Stricture of the nrcthra; fibroid 
degeneration in the lungs; 
dilated right ventricle of heart; 
liver cirrhosed ; hypertrophied 
brain. 


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Initials. 


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Feb. 2ist, 
1872. 

Jan. 24th, 
1872. 

Dec. 4th, 
1871. 


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CHEONIC BRICtHt's DISEASE WITH CONTRACTED KIDNEY. 369 

The arterioles in some cases were free from thickening, 
and the heart was nothypertrophied ; whilst there was chronic 
disease of the kidney, viz. large white kidney and so-called 
scrofulous pyelitis. 

Case 56. — This occurred in a patient named William E — , set. 33. He 
was in the London Hospital many weeks with great and general oedema, and 
the urine contained a large quantity of albumen. While in the hospital he 
had attacks of great dyspnoea, also of vomiting ; and a week or two before 
he died he had convulsions alternating with coma. 

The autopsy showed that the kidneys were larger and much heavier than 
natural. Their capsules separated readily ; their sui-faces were smooth and 
white, and very few vessels were seen. The kidneys had the peculiar, 
general, marble-white appearances so well represented by Dr. Bright in one 
of his drawings of Bright's disease. The cortical parts were much increased 
in size, and appear to be infiltrated with similar white material. Heart was 
normal. The arterioles of the pia mater were not thickened. 

Case 57. — In the case of a man who died in the London Hospital, under 
the care of Dr. Andrew Clark, there was general oedema ; the urine con- 
tained a large quantity of albumen, and there were symptoms of uraemic 
poisoning. The kidneys were in the morbid condition known as " large, 
white, and mottled." Heart was normal. The arterioles of the pia mater 
were carefully examined, and there were no indications of thickening. 

Case 58. — In a third case, a girl ast. 7 years, who died in the London 
Hospital under the care of Dr. Down, February, 1872, there were large 
white kidneys and general oedema. Heart was natural. The arterioles 
were not thickened. The disease in this case was of considerable standing, 
for the patient had been under Dr. Down's observation with albuminuria for 
more than twelve months, and she was in the London Hospital with kidney 
disease on more than one occasion. 

Case 59. — A foui-th case was that of George G — , set. 18. He was in the 
London Hospital several weeks with general oedema and a large quantity of 
albumen in the urine. He died with symptoms of ursemic poisoning. The 
autopsy on May 6tli, 1872, showed the kidneys weighed 14J oz. They 
were much larger than natural, and their capsules separated readily ; their 
surfaces were smooth and contained no cysts. They were of a pale fawn- 
colour, and a large number of yellow spots were seen scattered in the cortical 
parts. The cortex was greatly increased in size, and converted into similar 
fawn-coloured substance. These organs were good examples of large white 
kidneys in an advanced stage of disease. Heart weighed 8 oz. ; there was no 
dilatation or hypertrophy ; its valves and orifices were healthy. Liver, 
spleen, and lungs were healthy. The walls of the arterioles were not 
thickened. In the minuter ones the muscular nuclei were situated close to 
the outer edges of the vessel. 

24 



370 DISEASES OF THE VASCULAR SYSTEM. 

Case 6o. — A fifth case was that of William L — , set. 27, who died in the 
London Hospital. It was stated that he had been under the care of Dr. 
Thorowgood, at the Victoria Park Hospital, for many months, with symptoms 
of phthisis and strumous pyelitis. The capsules of the kidneys were very 
much thickened and the right kidney was adherent by old tough fibrous 
bands to the liver and intestines. On section this kidney seemed almost 
completely destroyed. It contained several cavities filled with thick puriform 
matter. There was very little kidney structure remaining. The left was 
similarly affected, but not to the same great extent. Heart healthy. 

The arteries of the pia mater were injected with Beale's Prussian blue 
solution, and afterwards carefully examined by aid of the microscope, and 
there were no indications of arterial thickening. 

In otlier cases (see case No. 13, James P — , set. 49) the 
kidneys were large, white, and mottled, the arterioles were 
thickened by hyaline-fibroid changes, and the left ventricle 
of the heart was dilated. 

In the latter case we cannot conclude that the kidney 
disease induced the morbid changes in the arterioles and 
heart ; for there is no evidence to show that the cardio- 
vascular changes did not precede the renal disease ; and the 
case of James B — , aet. 50 (see Case 18), tends to show that 
the cardio-vascular changes may be the primary and ante- 
cedent disease, and the renal changes subsequent. In this 
case the kidneys Avere highly congested and mottled, and a 
quantity of greyish-looking material was lying amongst this 
highly congested tissue. These kidneys were large and 
their cortex was much increased in size, and their surfaces 
were smooth. The morbid appearances were such as are 
usually seen when death has occurred in an early stage of 
acute nephritis, and they appear to show that the kidney 
disease had probably set in a few weeks only before 
death. The left ventricle of the heart was much dilated and 
hypertrophied, and many of the arterioles and capillaries 
were greatly thickened by the hyaline-fibroid changes. The 
cardio-vascular disease had, therefore, evidently preceded 
the acute renal changes. 

The arterioles are sometimes much thickened, whilst 
there is no kidney disease or very little morbid change in 
the kidneys. In support of this statement we may first 
mention the case of John C — , set. 34, who died of aneurism 
of the aorta. His kidneys were carefully examined, and 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 371 

they presented no signs of disease. The arterioles of the 
pia mater were much thickened by the formation of fibroid 
material external to the muscular nuclei. The kidneys were 
healthy and the arterioles thickened in the case of Sarah 
S — , 8et. 63 (see Case 2) ; also in the case of Samuel C — , 
get. 62 (see Case 19) ; also in the case of James D — , aet. 77 
(see Case 3) ', also in Case 2. 

In other cases there was little morbid change in the 
kidneys, no morbid change to indicate that their excretory 
power had been greatly diminished ; whilst the heart was 
much hypertrophied and the vessels much thickened. This 
is shown in Cases 7, 10, and 20. 

Note. — A reply to the above paper was published in the ' Medico-Chirur- 
gical Transactions,' vol. Ivi, 1873, entitled "The Pathology of Chronic 
Bright's Disease with Contracted Kidney, with special reference to the 
Theory of Arterio-capillary Fibrosis," by George .Johnson, ]\I.D. — (Ed.) 



DESCRIPTION OF PLATE V. 

Fig. 1. — The microscopical appearances seen in very granular contracted 
kidneys. (From a girl aged nine years.) 

The letter a points to six Malpighian bodies which are lying 
clustered together, and surrounded by a quantity of fibroid material. 
These bodies contain numbers of fat and other granules. A con- 
voluted tubule indicated by d is seen coming down from one of the 
Malpighian bodies with its epithelial cells destroyed. The letters B 
mark tubules which are lined with epithelial cells for the most part 
healthy, c points to isolated wasted tubules, containing shrivelled, 
ill-defined epithelial cells, and in some, in place of epithelium, 
nothing but fat-granules remain. 

Fig. 2. — Arteriole much thickened by coarse fibroid changes outside 
muscular layer ; tunica intima thickened also. 

Fig. 3. — Tunica adventitia and intima thickened by fibroid changes. 

Fig. 4. — Arteriole of the pia mater. Fibroid changes outside the mus- 
cular nuclei. 



FlcLte V. 






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n 






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CU 

.•. 'v^i^. C 



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:0^ 



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«tefe 



Fig 2 






"West, ITewiiia3:\ rt rrp . 



DESCRIPTION OF PLATE VI. 

Fig. I. — A capillary of the pia mater mucli thickened by a homogeneous 
hyaline substance. 

Fig. 2. — Capillary very much thickened by a granular substance. 

Fig. 3. — Hyaline-fibroid thickening outside the wasted muscular layer. 

Fig. 4. — The arterioles in the choroid greatly thickened by the formation 
of fibroid material outside the so-called muscular nuclei. The dark parts 
represent choroid pigment. 

Fig. 5. — Arteriole of skin thickened by fibroid formation outside mus- 
cular layer. 

Fig. 6. — Arteriole lying amongst muscular tissue of heart greatly thick- 
ened by the fibroid material. 

Fig. 7. — Minute artery of the kidney greatly thickened by hyaline- 
fibroid changes in the outer layer of the vessels. 



Plate "VI. 






j\ 




Fig 5 



If •'• '" 'W' 



T-ig^. 



'ig 6. 







Figl. 



Fiq 2, 



Fig 7. 



Affe st^ewiaatitm.j> . 



CLINICAL LECTURE 

ON 

CHRONIC BEIGHT'S DISEASE WITH 
CONTRACTED KIDNEY 

(ARTERIO-CAPILLAKY FIBROSIS).' 



The subject I liave chosen for your attention to-day is one 
for which the clinical wards of Guy^s Hospital are particularly 
famous. To use an expression of our German friends, Guy's 
Hospital is the " fatherland " of this disease. It was here 
that Dr. Bright pursued those investigations which have made 
his name immortal. " Bright's disease " is, however, but a 
generic expression, and appertains to many affections of the 
kidney which, though more or less allied by the character 
of their morbid anatomy, so far as the kidneys themselves are 
concerned, are probably distinct in their cause and clinical 
history. It has long been felt that the term '' Bright's 
disease " must either be discontinued, or be more strictly 
limited to one given pathological state. 

The object which I have in view on the present occasion 
is to make some remarks on that general condition which is 
perhaps more properly Bright's disease, and which is 
associated with one form of fibroid contraction of the 
kidneys. And here it should be observed that the kidney 
may undergo fibroid contraction and disorganisation, and 

1 Delivered at Guy's Hospital June 6th, 1872. Eeprinted from the 
'British Medical Journal,' December 2istj 18*2. 



376 DISEASES OP THE VASCULAR SYSTEM, 

cause death by uraemia, without being associated with that 
change in the heart and arteries upon which I desire to 
discourse in this lecture. In such cases the renal disease 
is probably due to some hereditary or congenital defect in 
the kidneys themselves, and is more strictly a local 
affection ; and although the results, so far as the kidneys 
are concerned, may be very much like, or even apparently 
identical with, the more morbid conditions arising under other 
circumstances, what constitutional accompaniments there are, 
are widely different from such as occur in the disease now 
spoken of. 

The form of chronic Bright' s disease with contracted 
kidney, now under discussion, is, it would seem, a more 
general affection : it occurs chiefly at or after the middle 
period of life. Some of its various phases were, no doubt, 
recognised by the physicians of former times, and vaguely 
assigned, even so early as the Greek physicians, to special 
epochs of life, denominated by them " climacterics." It is 
chiefly between what they would have termed the seventh 
climacteric and the ninth — that is, between the forty-ninth 
and sixty-third years — that this morbid condition occurs. 
I do not quote these terms to give any support to the 
idea that there are climacteric epochs ; but I may afiirm 
that the state of which I am speaking is a mode of decline 
from the climax of health and vigour of a special kind. 

As the facts of disease came to be more and more the 
objects of inquiry over mere symptoms at the bedside, and 
as morbid anatomy in support of such clinical obsei'vation 
was pursued more accurately after death, there would 
naturally be at first a tendency, with increased precision, 
to a somewhat narrow pathology ; for instance, the investi- 
gations of the intestines in typhoid fever led Broussais and 
his followers, as we know, to maintain that fever was a local 
intestinal affection. A similar error seems to have been 
committed in respect of this form of chronic Bright's 
disease. The common change in the urine during life, and 
the moi'bid state of the kidneys after death, have so closely 
confined the attention of physicians, that they have often 
looked no further than the kidneys and their failing 
function for the grounds of their pathology, and their patho- 



CHRONIC BRIGHt's DISEASE WITH CONTRACTED KIDNEY. 377 

log-ical views have been limited to tlie line thus indicated. 
Now, though no one will deny the almost paramount import- 
ance of keeping fully in view the results on different parts of 
the organism of defective renal excretion, and the tendency 
to death by uraemia, still we believe it can be no less main- 
tained that the fundamental clinical facts of the disease in 
question are not included in such limited causation, and 
cannot be understood by the conditions of a merely renal 
pathology. 

The constitutional form of chronic Bright^s disease with 
contracted kidney, or, as Dr. Sutton and myself have desired 
to designate it, " arterio-capillary fibrosis,'^ is, it would 
appear, a primary and general change in the capillaries and 
arterioles of the body, and corresponds, therefore, in its seat 
in the adult to the '' area vasculosa " in the embryo. And as 
it is the object of the embryologist to elucidate the changes 
through which the ovum proceeds upwards to the perfect 
development of its. tissues and organs, so it may be broadly 
stated to be the object of the pathologist to set forth the 
steps which lead downwards to death. There ai'e occasions 
which make it advantageous for the pathologist to enlarge 
the scope of his considerations by admitting this comparison ; 
for it is obvious that what is generally expressed by the 
term " vis formativa,''' whose resultant changes we see in 
development, is represented by the " vis conservatrix " in 
the adult, which failing, we have senility and death. 

Apart from accidental disturbances in the course of life, 
we might, perhaps, with due knowledge of the inherited 
forces, be able to predicate somewhat of the course of their 
failure. The curve of the ascent and the curve of the 
decline would, in other words, have some more or less exact 
coi'respondence, and we should be able to realise fully the 
truth that there is not only " a time to be born ^' and '' a 
time to die,^' but death might be predicted for a given 
individual to come in a certain time, say of any particular 
organ or of any particular system : for instance, we might 
be able to foretell that the failure would first appear in the 
nervous, or the vascular, or the secreting system. The form 
of chronic Bright's disease with contracted kidney is, 
it seems to us, one example of such (senile ?) decadence. 



378 DISEASES OF THE VASCULAR SYSTEM. 

Its clinical history varies in every case, according to the 
organ which suffers most and earliest. In one case, 
sleeplessness, headache, and other slight brain disturbances, 
may be the first symptoms complained of ; in another, the 
altered condition of the heart may first draw attention ; in 
a third, loss of appetite, dyspepsia, sickness, and failing 
digestion, are most prominent ; in a fourth, diuresis ; in a 
fifth, a liability to bronchitis, with attendant emphysema ; 
in a sixth, a state of general malaise, loss of strength, some 
emaciation, &c. 

These various phases, separately or in combination, con- 
stitute the earliest ailments for which the physician is 
commonly consulted. They are for the most part vaguely 
referred to a gouty condition ; and it must be admitted that 
the general morbid state of which we are speaking, though 
distinct from gout, is especially common in those whose 
ancestors have been gouty. It is often more erroneously 
referred to suppressed gout. This is less appropriate, since, 
except the vague flying pains to which such patients are 
liable, and the occasional deposit of uric acid or urates in 
the urine, there have often been no phenomena which could 
properly be termed gouty. 

In a large number of cases which come daily before the 
physician, no doubt the disturbances in question are no more 
than a mere variation in the general equilibrium of nutrition, 
which, by due care as to diet and exercise, and the other 
general conditions of health, are easily corrected ; but in a 
considerable number of persons they are the early signs of a 
general change in the vascular area, of which disease of the 
kidneys may or may not be an early and prominent part. 

And here I may refer to the evidence supplied by the 
urine at the outset of chronic Bright's disease with con- 
tracted kidney. Hitherto it has been the habit of the 
clinical physician to take the specific gravity of the urine, 
and to test it for the presence of albumen. Should the 
specific gravity be normal (1020 to 1024), and should no 
change in the fluid be produced by heat and nitric acid, 
whatever ailments have been present, they have not been 
referred to the early stages of Bright's disease, but have 
been explained, as I have said above, by reference to some 



CHEONIC BEIGHt's DISEASE WITH CONTEACTED KIDNEY. 379 

gouty condition, or to some limited change, — functional or 
otherwise, — in the part complained of : for instance, if in the 
stomach, to the food taken ; if in the chest, to catarrh from 
cold. If flying pains have been complained of, they have 
been referred to neuralgia or rheumatism ; if headache, to 
overwork, &,c. But, assuming that we have to do with a 
case of coming Bright's disease in so early a stage, the 
following may be considered as not uncommon clinical con- 
ditions. The heart may be even already thickened so far 
as to produce an increased impulse over an increased area. 
These signs of hypertrophy are somewhat more obvious, as 
already there may be a loss of subcutaneous fat, and, although 
not very marked, a further distinct loss of weight. 

In a case that lately came before me, the patient, a 
gentleman aged 53, although he made no mention of 
emaciation, yet, when questioned, said his weight had de- 
clined within a year from 14 st. 1 1 lbs. to 13 st. 1 1 lbs. 
Cardiac hypertrophy under these conditions may have no 
connection with valvular disease. Indeed, at an early stage 
both the loss of weight and the hypertrophy of the heart 
may easily be overlooked ; the hypertrophy especially, as 
the cardiac sounds may have undergone no change, or only 
a slight loss of distinctness in the first sound. 

The examination of the urine at this stage gives varying 
results. For the most part, there is no discoverable change 
from health, or only the presence of a faint and doubtful 
opalescence after boiling and the addition of nitric acid. 
Even this change may be absent altogether till later on in 
the disease, or before it becomes constantly present we may 
find albumen only in the urine passed after food. The 
presence of albumen may also alternate with the deposit of 
urates or uric acid. Albumen is often altogether absent 
when these deposits are present ; but the relations of albumen 
to the deposits of uric acid and urates of soda and ammonia 
are by no means constant. These deposits and the albumen 
may occur together in the earlier stages of fibrosis of the 
kidney. It is by no means uncommon for even careful 
observers to overlook or lightly estimate the early indications 
which the urine thus affords of commencing fibroid cachexia. 

Although the renal change is probably but part and 



380 DISEASES OF THE VASCULAR SYSTEM. 

parcel of a general state of morbid changes, the clinical 
value of the evidence afforded by the urine in the early- 
stages in many cases is most important. It is desirable to 
examine the urine passed at diiferent times of the day. The 
early morning urine may be normal in colour and weight 
(sp. gr. 1018 — 1022). That passed at noon may be still 
without deposits on cooling (1022 — 1024), with or without a 
faint opalescence after heat and nitric acid. That passed 
at 6 p.m. (assuming the dinner to be a late one) may be 
neai'ly the same as that at noon. That passed on going to 
bed may deposit urates, sometimes with, sometimes without 
faint change from albumen by heat and nitric acid (sp. gr. 
1024 — 1026). It is at this early stage that the symptoms 
are vaguely referred to disorder of the liver or the stomach. 
Those physicians whose minds are made up as to the 
cause of the cardiac hypertrophy in chronic Bright's disease 
may insist that even already there may be such a defective 
excretion from the kidneys as so far to interfere with the 
physiological relations of the blood to the tissues, that it 
cannot pass through the systemic capillaries without an in- 
creased impulse from the heart, and that the hypertrophy is 
so caused. But the assumption of such an altered state of 
the blood as a true cause of the hypertrophy is entirely 
unsupported by any observations on the blood itself, and is 
not supported by evidence on the side of the urine itself. 
The specific gravity, as stated above, may be normal ; the 
quantity and colour may be normal ; the cold urine treated 
with nitric acid may become as usual nearly solid with 
nitrate of urea ; and the only change, and this but occasional, 
may be a faint opalescence, under heat and nitric acid, due 
to the presence of albumen. No doubt in a more advanced 
stage tbe uric acid and the urates may cease altogether to 
be deposited as the urine cools. The urine loses colour and 
specific gravity, and is considerably increased in quantity, 
though still in general free from all deposits of desquamated 
epithelium ; as the albumen increases, it contains very trans- 
parent fibrinous casts, which are complementary of the 
albumen of the liquor sanguinis, and equally due with it to 
mere passive transudation. When these changes in the 
urine have become more mai'ked, and the general cachexia 



OHEONIO BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 381 

is advanced, the renal affection is set down naturally, if tlie 
case is seen at this stage for the first time, as a primary 
cause of all the attendant changes, cardiac and capillary ; 
but such a view seems to my colleague and myself to be an 
erroneous one, and to have arisen from a deficiency in our 
early clinical knowledge of such cases. Nor can this 
deficiency be easily supplied from hospital practice. 

Poor men who are dependent upon bodily labour for 
their livelihood do not so often present themselves at hospitals 
in the early stages of disease. It is in private practice that 
we have to make good our wants in these particulars, and 
even here the scientific cultivation of medicine suffers by 
the readiness to explain away the causes of ailments down 
to the comprehension of the uninformed. It is, besides, to 
be noticed, that even when our hospitals afford evidence it 
is indistinct. In an early stage of fibroid cachexia, persons 
are apt to die of acute disease in the brain or lungs before 
the amount of renal change is enough to give it any I'ecog- 
nised clinical significance. These early deaths take away 
from us the opportunity of observing the further course in 
such cases of the renal degeneration which, apart from such 
accidents, might soon have become a prominent clinical 
feature, though it escapes attention when less marked -, 
and the subject is dismissed with only this recognition, 
that the kidneys are coarse. I do not see how we could 
easily have escaped from the trammels of a narrow patho- 
logy, and, if I may be permitted to say so in respect of the 
matter under discussion, from its vicious influence on 
practice, if our observations had continued to be limited 
to the more prominent lesions of advanced ''Bright's 
disease ^' as they present themselves at the bedside, and even 
on the post-mortem table. 

It is the facts of the eai"ly stage of the disease in some 
cases which amply demonstrate the insignificant part which 
the morbid state of the kidney, when present at this stage, 
may then play. I repeat the early stage in some cases, 
for a further and greater difficulty in the due appreciation 
of this morbid state arises from the fact that the fibroid 
changes often come on early, and advance far in the kidneys 
before other parts are very much affected. Still it is to be 



382 DISEASES OF THE VASCULAR SYSTEM. 

remarked that when this is so the renal change is of precisely 
the same nature, and has the same seat, so far as the several 
tissues are concerned, as when it occurs early in the capil- 
laries elsewhere. That is, I ought to add, if the disease be 
the one under discussion ; since, as I have before stated, 
there is a local as well as a constitutional fibroid change of 
the kidneys. And this brings me to the most important 
confirmatory fact, showing that mere renal destruction does 
not produce the state we are discussing. Hitherto it has 
been assumed and generally admitted that chronic Bright' s 
disease with contracted kidney has always essentially a 
local origin, and is limited to the kidney in its beginnings, 
and that the changes in the heart and ai'terial system are 
the natural and proper sequelge of imperfectly depurated 
blood. Dr. Bright says, speaking of the changes in the 
heart, " The most ready explanation appears to be that the 
quality of the blood is altered by the kidney disease. The 
blood in consequence affects the minute and capillary circu- 
lation so as to render greater action necessary to force it 
through the vascular system." This explanation has been 
most generally accepted since Bright's time. Dr. George 
Johnson, to whom we are indebted for much valuable informa- 
tion on renal pathology, fully endorses this opinion, and 
maintains that there exists a corresponding hypertrophy of 
the muscular coats of the capillaries compensatory of the 
cardiac hypertrophy, which acts as a stopcock on the 
minuter vessels to hinder the afflux of the unwholesome blood 
to the tissues. 

I shall presently have to speak of this change in the 
smaller arteries (arterioles) and capillaries, and to assert 
that probably they are not hypertrophied, and that the 
physiological purpose here mentioned is not founded in fact. 
But first as to the effect of imperfectly depurated blood — 
uraemia — on the heart. It seems to have been too readily 
assumed, in accordance with an experiment by the late Dr. 
John Reid, which showed that during asphyxia there is an 
increased pressure on the arterial walls, that a similar state 
of arterial tension occurs if the blood be imperfectly 
depurated by the kidneys, and that, this state of tension 
being continued, hypertrophy of the heart is the result. 



CHEONIC BRIGHT's DISEASE WITH CONTRACT I'^D KIDNEY. 383 

But is the effect of blood imperfectly depurated by the 
kidneys, that which is thus asserted ? Dr. Wilks mentions 
that the heart is free from hypertrophy in many cases of 
large white kidney. Dr. Dickinson says that simple 
hypertrophy of the left ventricle is rarely associated with 
any form of renal disease, except granular degeneration. 

Dr. Grainger Stewart found the heart hypertrophied in 
only about four per cent, of the cases of lardaceous disease 
of the kidney. To these facts might be added others of a 
similar kind, such as scrofulous and cystic degeneration of 
the kidneys. Many of these forms of renal disease are slow 
in their progress and destructive of the renal function, and 
they often occur at that period of life when hypei'trophy 
would be readily produced to meet any impediment to the 
systemic circulation, and yet it does not occur. 

A full consideration of all the circumstances makes it, in 
fact, more than doubtful whether mere defective renal excre- 
tion is a sufficient cause of cardiac hypertrophy. It may, 
perhaps, be objected that the hypertrophy may still depend 
upon some particular form of renal degeneration. In this. 
Dr. Sutton and myself are disposed entirely to concur, but 
not in the sense generally admitted. It is, we believe, 
when the fibroid change in the kidneys is part and parcel of 
a fibroid change in the capillaries of the body generally, 
that the cardiac hypertrophy occurs. Though associated 
Avith renal disease, the hyperti^ophy is not produced by it. 
To prove how little mere fibroid atrophy of the kidneys, 
when a local affection, can produce the cardiac and other 
changes usually attributed to it, I might quote cases of such 
change in the kidneys in young subjects, in whom, however, 
after death the heart was not thickened. I might refer to 
cases also given me by my friend Dr. Moxon ; but I prefer on 
the present occasion to draw attention to one of such cases 
recorded by Dr. Murchison in the ' Transactions of the 
Pathological Society,' vol. xxii. And I do this with the more 
confidence, because in all its important details it corre- 
sponds with what I have myself observed to occur from time 
to time in young subjects of either sex, and is not brought 
forward by Dr. Murchison in reference to this subject 
at all. 



384 DISEASES OF THE VASCULAR SYSTEM. 

Walter F — , aet. i8, was admitted into Middlesex Hospital May ptli, and 
died May 13th, 1S71. His father, mother, brother, and sister were alive 
and well. There had been no more in the family. Ten days before admis- 
sion to the hospital he was seized rather suddenly with pain at the pit of the 
stomach, palpitations, and dyspnoea on exertion. Two hours previously he 
carried a heavy tray of plates fifty yards, and had experienced no inconveni- 
ence at the time, though he attributed the attack to this cause. After this 
he lost appetite, and died on the 13th of the month, four days after admis- 
sion. The body was well nourished, and showed no signs of chronic disease, 
and he sank apparently from nrsemia. The urine drawn ofE by a catheter on 
the day of his admission was limpid and colourless, like water. Its specific 
gravity was 1007. It contained phosphates, and a decided, though small, 
trace of albumen. The apex of the heart beat between the fifth and sixth 
ribs rather tumultuously ; the transverse dulness did not exceed an inch 
and three quarters. On a post-mortem examination the " heart and blood- 
vessels icere healthy." " The only organs diseased," says Dr. Murchison, 
" were the kidneys, both of which were extremely small, the right weighing 
one ounce and a quailer, and the left three quarters of an ounce. On 
section they had a uniform, pale, firm tissue, which on microscopic examina- 
tion showed very much the same characters as those of an ordinary contracted 
granular kidney." 

I desire to show from this case, as I could from others of 
a similar kind, that in young subjects renal degeneration from 
local fibroid changes in the kidney may lead to a fatal issue 
through defective excretion, without any hypertrophy of the 
heart being produced. If defective renal excretion alone led 
to arterial tension as supposed, it is highly probable that, 
if it occurred in a young subject, in whom the nutritive 
conditions are active, it would, a fortiori, lead to cardiac 
hypertrophy. It may be objected, that the course of the 
case was too short for this result ; but Dr Murchison says, 
''Whatever view be taken of the renal lesion, it is quite 
clear that it had existed a long time prior to death." It 
would thus appear that fibroid renal disease alone is not a 
sufficient cause of cardiac hypertrophy. In the case here 
recorded, the pale and light urine was indicative of extreme 
renal degeneration. The blood was so imperfectly depu- 
rated as to cause a fatal issue. The course of the case must 
have been chronic ; and j'et the heart was entirely free 
from hypertrophy. But whilst, on the one hand, the heart 
may remain free from hypertrophy, in the long-continued 
presence of blood so imperfectly depurated by the kidneys 
as at length to become fatal ; so, on the other hand, daily 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 385 

experience shows that, at the period of life when the 
general fibroid cachexia is most common, cai'diac hyper- 
trophy begins and advances to its extreme limits whilst the 
morbid changes in the kidney are indistinct or early, the 
kidneys being no more than coarsely granular if obviously 
affected at all. In illustration, I might direct attention to 
the frequent occurrence of death by ingravescent apoplexy, 
at the age of from forty-five to fifty years, where the left 
ventricle of the heart is often extremely thickened, but the 
kidneys still unaffected, or, in the early stage of fibroid change, 
coarsely granular. 

The observations which my friend Dr. Sutton has made 
upon the arterioles and capillaries, afford evidence that in 
this form of Bright^s disease there is a more or less general 
alteration of the smaller arteries (arterioles) and capillaries 
throughout the body. To begin with the kidneys them- 
selves, it would appear, in accordance with the views of 
many other observers, among whom I ought chiefly to name 
Dr. Dickinson, that the morbid change alluded to begins in 
the intertubular tissues, and principally in and around the 
smaller arteries and capillaries. The vascular coats are 
altered and thickened by the formation of a fibroid or 
hyaline-fibroid substance. This change affects the tunica 
intima and the external tunic of the vessels, whilst the 
muscular coat presents various appearances. 

Dr. George Johnson has expressed the opinion that the 
alteration in the muscular coat is simply one of hypertrophy, 
and is due to a continued stimulus in the vessels to meet the 
increased action of the heart, according to the views above 
quoted. Dr. Beale, who has referred to this matter, thinks 
with ourselves, that the thickening of the vessels has been 
too hastily assumed to be one of hypertrophy. Dr. Beale's 
views on this part of the subject — I mean as regards the 
vascular changes in the kidneys — are entirely in accordance 
with what has been seen both by Dr. Sutton and myself. 
We have found the muscular nuclei often indistinct, and 
in some cases hardly to be recognised ; and, although there 
may be an appearance of hypertrophy in some parts 
of a vessel, it is, as Dr. Beale states, associated with 
great change and degeneration of the normal tissue in 

25 



386 DISEASES OF THE YASCULAE SYSTEM. 

adjacent parts. In confirmation of this, Dr. Beale goes on 
to say (Dr. Beale 'On Kidney Disease/ pp. 71, 72), "The 
new tissue added is completely destitute of the properties 
characteristic of a healthy structure. It is true that we 
speak of hypertrophy of the muscular coat of the intestine 
and of the bladder, although the tissue may have lost all 
contractile power ; but it is obvious that the word hyper- 
trophy is inapplicable, and ought to be restricted to those 
cases in which there is not only increased bulk but an in- 
creased development of a tissue without impairment of 
function. In hypertrophy of the heart, and of the muscles 
of the limbs, there is increased formation of healthy muscular 
tissue, and a corresponding increase of muscular power; but 
in the case of these thickened arteries, thickened bladder, 
intestine, &c., there is an increase of substance depending 
upon the formation of an abnormal tissue with impaired 
action or loss of healthy function altogether. In the case of 
the thickened arterial coats there is an increased bulk 
with altered structure, not simply increased bulk without 
change in structure (hypertrophy). Careful observation 
leads me to remark, in the first place, that the muscular 
fibre-cells are much less distinct than in the normal state. 
The oval nuclei are to be readily distinguished, and are often 
increased in size and number, but the contractile tissue has 
degenerated into mere fibrous tissue, which possesses no con- 
tractile power whatever. Secondly, the connective tissue 
external to the muscular fibre-cells is often enormously 
thickened, and all indications of the delicate nerve-fibres 
which ramify in this situation in health are lost. Thirdl}^, 
the calibre of the small arteries is considerably reduced, 
partly perhaps from deposit taking place internal to and 
amongst the muscular fibre-cells ; partly to the reduced 
quantity of blood traversing them, but mainly to the in- 
creased deposition of new material externally in what was 
the areolar coat of the vessel. '' 

So far, therefore, as the vascular morbid changes in the 
kidney go, there is some unanimity amongst observers as to 
their character, and there is further some agreement as to 
their being primary and not secondary to morbid changes in 
the secreting epithelium, as was supposed by Dr. Bright, 



CHRONIC BRIGHT's DISEASE WITH CONTRACTED KIDNEY. 387 

and is now maintained by Dr. G, Johnson. The early 
change in the renal epitheliura, upon which so much stress 
has been laid, appeal's to be largely, if not entirely, due to 
passive transudation from the vessels, in the act of dying, 
since similar or even identical appearances are common in 
the renal epithelium in kidneys otherwise healthy. It is 
certainly by no means confined to Bright^s disease ; and it 
is usual to find it in kidneys which present no signs of 
lesion except purely mechanical venous congestion. 

We believe that the changes in the secreting epithelium 
will be found to be secondary to the intertubular changes 
around the vessels, and not, as Dr. Gr. Johnson believes, 
primary and essential. This view is confirmed by the 
condition of the capillaries in other organs. In the lungs, 
in the stomach, in the skin, in the spleen, in the heart, in 
the retina, and in the membranes of the brain, the arteri- 
oles and capillaries have been found in an abnormal state, 
from a formation of fibroid or hyaline-fibroid substance 
similar to that which occurs in the arterioles of the kidney. 
This morbid change in the vascular system, more or less 
throughout the body, varies much, however, in different 
cases, both as to its prevailing extent in any organ, and as 
to the organ primarily or chiefly affected by it. In some 
cases, and probably in the great majority, the kidneys are 
much altered, whilst the heart is at the same time hyper- 
trophied, and the minute arteries and capillaries are 
proportionately thickened. In others the kidneys may be 
but little affected, whilst the heart is much hypertrophied, 
the systemic arteries and capillaries being at the same time 
thickened by fibroid change. 

It is this wide-spread change in the vessels, together with 
a tendency to atrophy of the surrounding structures, which 
constitutes, we believe, the essential pathology of " chronic 
Bright's disease with contracted kidney." 

It is a change, as before remarked, which occurs chiefly 
at or after the middle period of life. And yet the age of a 
patient is not commonly to be estimated by years. Here- 
ditary predisposition, habits of life, and other circumstances 
which may lower the vitality of the tissues may induce at a 



388 DISEASES OF THE VASCULAR SYSTEM. 

much earlier period than forty-five conditions which do not 
usually supervene till many years later. 

The conclusions at which Dr. Sutton and myself have 
arrived, are briefly these. i. That there is a diseased state 
coming on about the middle period of life, which is charac- 
terised by a morbid formation of fibroid or hyaline-fibroid 
tissue in the arterioles and capillaries. 2. That this is 
accompanied with atrophy of the adjacent tissues in varying 
degrees. 3. That this morbid change commonly begins in 
the kidneys, but may begin primarily in other organs. 4. 
That the contraction and atrophy of the kidneys is not a 
cause of the disease, but only part and parcel of the general 
morbid state. 5. That hypertrophy of the heart is due to 
changes in the arterioles and capillaries, whereby their elas- 
ticity is diminished and so the blood retarded. It is not 
due to a morbid condition of the blood itself. 6. That the 
blood may be fatally affected by disease of the kidneys 
without producing any change in the heart, provided the 
morbid condition of the vessels alluded to is absent. 7. 
That the causes which lead to these vascular changes are 
not yet fully elucidated. 8. That they have an alliance 
with senile conditions, though probably they are in their 
nature distinct. 

If we turn to the therapeutical bearings of this subject, 
the discussion of its true pathology does not lessen in import- 
ance. At the present time there is a dominant idea in 
respect of chronic Bright's disease with contracted kidney, 
that the various functional disorders and lesions which occur 
in its course are chiefly, if not entirely, connected with a 
materies morbi in the blood, to which such disorders and 
lesions are chiefly referable. The therapeutics of the day 
are largely directed according to this idea. Like most 
theories respecting the materies morbi of different diseases, 
whether we regard the elimination of the poison of cholera, 
the neutralisation of an acid in the blood in rheumatism, the 
destruction of it by colchicum in gout, or the antidote to 
some septic poison in fever, the theory that all or most of 
the symptoms in chronic Bright's disease are due to uraemia 
is frequently fraught with dangerous and destructive effects 
in practice. 



CHRONIC BEIGHt's DISEASE WITH CONTEACTED KIDNEY. 389 

I call vividly to mind the unhappy results of treatment so 
directed : the vapour-baths and antimonials of former times 
for eliminating through the skin ; the compound jalap 
powder and elaterium, to call forth the vicarious functions 
of the intestinal mucous membrane, ef csetera similia, — such 
or similar treatment tended, no doubt, to exhaust the already 
failing nutritive powers. 

Although, in respect of the ureemic state, the faulty con- 
dition of the blood and its treatment by eliminants cannot 
be neglected, still it must be admitted that there is an im- 
portant distinction between the ui-ajraic state and its conse- 
quents, and that general fibroid cachexia (?) which exhibits 
itself in the arterioles and capillaries of the different organs, 
as now under discussion. The two may no doubt be com- 
bined, and indeed are often combined, in the same 
individual ; but still, for therapeutic purposes, it is of no 
small importance to the sick man, that as exact a perception 
as possible of the distinction here insisted on should be 
acquired. 

Whilst we cannot leave out of consideration the changes 
in the blood, neither can we safely forget that there are 
important antecedent and comcomitant tissue changes which 
are independnt of mere urceraia. 

I have not time fully to discuss, even if it were my duty 
to do so on this occasion, all the clinical bearings of this 
subject. My colleagues, your present teachers, are as fully 
alive to the necessity of extending our views on this subject 
as I myself can be. They will, I am sure, tell you that 
many of the diseases of the brain, of the lungs, of the heart, 
and of the stomach, are associated with, and form part and 
parcel of, this great malady. When treating of apoplexy, 
they will say that over and above the cerebral affections 
which are due to uraemia, and which were first of all so well 
described in this place by my late colleague, Dr. Addison, 
the brain tissue is liable to subacute or chronic lesion, from 
disease of its capillary vessels ; that acute pneumonia, or 
bronchitis, at the period of life of which I have spoken, is 
often due to already commencing vascular disease ; that 
dyspepsia, and especially the so-called gouty dyspepsia, is 
not the result of a materies morhi floating in the blood, but 



390 DISEASES OP THE VASCULAR SYSTEM. 

of a subacute or chronic degeneration of the mucous 
tissue. 

Here, as elsewhere in the therapeutics of disease, the 
limitation of our thoughts to the conditions of the moment, 
or to the special organ affected, cannot but be productive of 
either fruitless or dangerous practice. It is always danger- 
ous to rest in a narrow pathology ; and I believe that to be 
a narrow pathology which is satisfied with what you now see 
before me on this table. In this glass you see a much 
hypertrophied heart, and a very contracted kidney. This 
specimen is classical. It was, I believe, put up under Dr. 
Bright's own direction, and with a view of showing that the 
wasting of the kidney is the cause of the thickening of the 
heart. I cannot but look upon it with veneration, but not 
with conviction. I think, with all deference to so great an 
authority, that the systemic capillaries, and, had it been 
possible, the entire man, should have been included in this 
vase, together with the heart and the kidneys ; and then we 
should have had, I believe, a truer view of the causation of 
the cardiac hypertrophy, and of the disease of the kidney. 



ON CHANGES 

IN THE 

SPINAL COUD AND ITS VESSELS IN 
ARTEEIO-CAPILLAEY EIBEOSIS.^ 



Bepoee entering upon the morbid changes which are the 
subject of this communication, it may be permitted us to 
state some general conclusions on arterio- capillary fibrosis 
to which our observations have led us. 

In May, 1872, we recorded in the 'Transactions' of 
another Society a series of observations on the morbid state 
commonly called chronic Bright's disease with contracted 
kidney, and affirmed that there are (i) not only the well- 
recognised, and we may say, notorious cases in which the 
kidneys are contracted, the heart much hypertrophied, and 
the vessels diseased, but there are (2) others in which the 
kidneys are but slightly affected, and yet in which the heart 
is equally hypertrophied and the vessels diseased, and (3) 
other cases in which the heart is hypertrophied, the vessels 
diseased, but without disease of the kidney of the kind in 
question, or merely the congestion of the dying. In all 
these three classes of cases we have observed fibroid 
changes in the arterioles, capillaries, and interstitial tissue of 
various organs. On these grounds we expressed the opinion 

1 By Sir WilUam Gull, Bart., M.D., and H. G. Sutton. Eeprinted from 
the ' Pathological Society's Transactions,' vol. xxviii, 1877, p. 361. 



392 DISEASES OF THE VASCULAR SYSTEM. 

tliat the pathology of the state commonly called chronic 
Bright's disease with contracted kidney was not essentially 
renal, and that for its full comprehension a wider investiga- 
tion of concomitant or even antecedent changes in other 
organs was called for. Since the time named we have 
prosecuted these investigations more or less continuously 
throughout the several organs — stomach, spleen, liver, lungs, 
heart, cord, brain, skin. 

If further inquiry should establish, as it seems to us 
assured that it will, that after the middle period of life, 
there is very commonly a pathological condition of the body 
which leads to fibroid changes, not only in the kidneys, but 
more or less generally in other organs, then we may conclude 
that the renal affection, being of the same kind and charac- 
ter, is probably but a more pronounced local expression of a 
general disease or degeneration. 

Clinical medicine from this point of view would recognise 
the significance and bearing of many now supposed unim- 
portant ailments ; and might find that these ailments are 
signs of commencing tissue-chauges of the kind in question, 
springing up in one or more of the several organs, it might 
be in advance of renal changes, and foreboding their advent. 
But lest we should be misunderstood as too much limiting 
this inquiry, we would state that our investigations lead us 
to think that these tissue-changes may in some cases result 
from the renal disease ; whilst in others they may follow 
the renal changes in respect of time, but not be dependent 
upon them, but upon a general cachexia of which the renal 
disease is part. 

Everyone will admit that the progress of pathology must 
be made by retracing the steps which lead to morbid ana- 
tomical results. In chronic Bright's disease with contracted 
kidney, the kidneys and the thickened heart, the two most 
prominent features, have mostly occupied and satisfied the 
attention, whilst antecedent or attendant changes in the 
other organs have been but little considered ; or, further, 
indeed, when such changes with hypertrophy of the heart 
have occurred without the prominent lesion in the kidneys, 
they have been too much regarded as isolated facts. We 
believe it will be proved that these collectively indicate 



CHANGES IN THE SPINAL COED AND ITS VESSELS, ETC. 393 

in common a state having arterio-capillary fibrosis as its 
basis. 

Respecting the objection which was raised by Dr. 
Johnson, that what we had regarded as a pathological change 
in the arterioles and capillaries was a merely artificial result, 
we have only here to state, with due respect to him, that 
continued investigations have but strengthened our views ; 
and the observations we have now to submit on the cord 
will probably leave little doubt in the minds of others that 
the changes in the arterioles and capillaries are morbid. As 
to the hypertrophy of arterioles, we may say, as we did in 
our earlier communication, that though the muscle in some 
of the larger arterioles especially seemed to be increased, 
yet we are still sensible of the difficulty of giving a true 
interpretation to such an appearance. As to the question 
whether the muscular layer of the arterioles in any particu- 
lar instance be hypertrophied, assuming the several elements 
to be normal, or whether the thickened appearance in such a 
case is the result of unusual contraction of the vessel, we 
have not, as we say, been able fully to satisfy ourselves. 
The problem is beset with special difiiculties, and obviously 
greater ones than can arise in determining whether the arte- 
rioles be the seat of moi'bid changes in their tissues or not. 
Moreover, we know of no observations showing that the 
muscular layer has a constant thickness in arterioles of 
equal calibre. 

Nor is it always easy to say whether the adventitia of an 
arteriole is thickened if it be separated from its surround- 
ings. At all events, in a doubtful case, we are much aided 
by seeing how the apparently thickened adventitia is in con- 
tinuity with the increased connective tissue about it, and 
how the fibroid changes spread from the vessels to the 
surrounding textures. 

But whatever conclusion shall be arrived at respecting 
the hypertrophy, we maintain that the muscle layer in many 
arterioles in chronic Bright's disease and the general state 
associated with it, is atrophied, and associated with a hyaline- 
fibroid change in arterioles and capillaries. 

In submitting our observations on the spinal cord, we 
desire to add that we have extended our inquiries to other 



394 DISEASES OF THE VASCULAE SYSTEM. 

organs, and are prepared to show that there ai*e similar tissue 
changes in various seats and amount throughout the body 
in this morbid state. 

This communication we regard as but part of a series 
growing out of our former inquiry, and enlarging our con- 
clusions recorded in 1872. 

We believe that many, if not most, of the textural changes 
in the cord, will be seen to be similar in kind to those which 
characterise the fibroid contracted kidney. Hereafter we 
purpose to show from observations already made that the 
same character of lesion occurs in stomach, spleen, heart, 
lungs, brain, skin, &c. 

The sections of the spinal cord which we now bring for- 
ward, are prepared in the usual way, hardened by chromates, 
stained with logwood or carmine, or anilin black, and 
mounted in Canada balsam. 

Before entering upon the morbid changes in the cord in 
cases of ai'terio-capillary fibrosis, it may be useful to recall 
some particulars of the normal histology. 

The surface of the cord is bounded by connective tissue, 
which is simply part of its pia mater, and processes of the 
same penetrate at many points into the white matter. Many 
of the larger processes (septula) pass in a straight direction 
inwards ; but, in doing this, they give off branches, and 
enclose groups of nerve-tubules, making it not difficult to 
imagine that the columns of the cord are compai'able to a 
fasciculus of medullated nerves, bound together by connec- 
tive-tissue sheaths which are the remains, or at all events 
the representatives, of the neurilemma. The thinner branches 
of the septula give off still more slender processes, and the 
finest of these pass between and separate individual tubules. 

By this branching and communication, a connective-tissue 
plexus is formed, in the meshes of which the nerve-tubules 
lie as in a stroma. Gerlach estimates that the most attenuated 
divisions do not exceed '008 of a millimetre in thickness. 
The septula of connective tissue in the lateral columns near 
the grey matter are thicker than in many other parts, and 
thicker in the posterior than in the anterior columns, and 
especially near nerve-roots. 

Opinions have differed as to the structure of the septula. 



CHANGES IN THE SPINAL COED AND ITS VESSELS, ETC. 395 

but Gerlach says the larger are made up of slightly sinuous 
fasciculi of the very finest connective-tissue fibrillge, which 
run mostly horizontally to the long axis of the body. Our 
observations support his opinion (see PI. VII, figs, i and 2.) 
If the connective tissue from the septula be traced in- 
wards until the finest divisions of the plexus are reached, 
we see, in transverse sections of the cord, nuclei lying here 
and there between the nerve-tubules. Immediately sur- 
rounding these nuclei is a small amount of protoplasm ; and 
from this protoplasm radiate two, three, or more, exceedingly 
slender caudate processes, which divide and subdivide and 
pass between the tubules. It is these caudate fibrils which 
constitute the finest intertubular branches of the con- 
nective tissue (see PI. VII, fig. 2). These connective- 
tissue nuclei with their caudate fibrils are especially well 
seen in the columns of the cord, near to the grey matter 
(see PL VIII, fig. i), and with their protoplasm are 
particularly distinct in the anterior columns, near to the 
anterior median fissure. But they may be found in almost 
every part of the white matter. They are better brought 
out by logwood dye than by carmine. In addition to these 
elements there is a finely granular and homogeneous sub- 
stance (neuroglia) which embeds the tubules. This neuroglia 
is considered by some observers to be simply a modification 
of the connective tissue, interlaced by elastic fibres. 

A line bounds the outer edge of the medullary sheath, 
and separates it from the neuroglia. We are disposed to 
agree with those who look upon the concentric appearance 
commonly seen in the medullary substance of the nerve- 
tubules, especially in chromic acid preparations, as an arti- 
ficial production. 

Of the grey matter, for our purpose, we need not say 
more than that the nerves are surrounded by neuroglia, but 
without the fibrillar connective tissue as in the white matter ; 
and that a connective-tissue plexus supports the columnar 
epithelium of the central canal. Outside this is a very fine 
nerve-plexus, and a number of scattered spherical bodies, which 
are thought to be connective-tissue cells. The nature of some 
of these bodies is uncertain. The distribution of the vessels 
in the cord is not yet fully determined. Artificial injections 



396 DISEASES OF THE VASCULAR SYSTEM. 

show arterioles and capillaries ramifying in the septula of 
connective tissue. These vessels are often seen in the sep- 
tula naturally injected. The capillaries and arterioles of 
the grey matter are generally seen without difficulty. The 
arteriole and vein on each side of the central canal are 
familiar objects. 

We have given these bi-ief particulars of the healthy cord, 
with the object of rendering our description of the patho- 
logical alterations more intelligible. 

These alterations will perhaps be better understood if we 
describe first the slighter and more recent, and subsequently 
the more advanced and complicated changes. 

We first describe (Case i) the changes which we think 
are due to oedema — simple exudation as part of a more or 
less general oedema. In a section of a dorsal cord^ are 
seen many small homogeneous masses, well stained ; these 
vary much in size : some are only as large as the area of 
one nerve-tubule, while others occup}^ the area of two or 
three. The edges of these masses are notalways well defined ; 
they fade off gradually into the adjoining structures. As 
many as twenty to thirty of these masses can be counted at 
one time in the field (150 diameters). They are present in 
this case in all parts of the white matter, but are more 
numerous in the deeper parts of the columns. These masses 
are simply diffused amongst the nerve-elements and con- 
nective tissue. This is evident by noticing that although 
the homogeneous stained substance may conceal the axis- 
cylinders and medullary sheaths, yet, if the focus be altered, 
these structures are seen lying, seemingly little or not at all 
changed, amongst the stained homogeneous matter. Similar 
homogeneous substance is noticed also collected around 
some of the capillaries, and so much so that the wall of the 
vessel is buried in it. Still it is to be noted that most of 
the collections are not in immediate contact with arterioles. 
Besides these homogeneous masses, there is also a hazy sub- 
stance, probably of the same nature as the above, but less 
in amount, and therefore more faintly stained, apparently 
pervading many of the medullary sheaths, and even ex- 
tending into axis-cylinders, and also a few collections of yellow 
' Case of W. L— (PI. IX, figs, i and 2). 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 397 

(haematin) granules. These defined homogeneous masses 
correspond to what have been called colloid bodies (see PI. IX, 
fig. 2, /3). The fibrils of the connective-tissue cells appear 
thickened in many parts. Whether this apparent thicken- 
ing be due to exudation around the fibrils, or to an increase 
of the substance of the fibrils themselves, may be open to 
question. The protoplasm around the connective-tissue 
nuclei appears increased, but the nuclei themselves of the 
connective tissue appear in this case mostly normal, but 
some seem swollen and are aggregated together in parts in 
twos and threes. The vessels are for the most part not 
noticeably thickened. Some axis-cylinders in one of the 
sections of the anterior column are enormously enlarged by 
exudation, or, at least, by some material which took the dye 
well (PI. IX, fig. i). 

In the spinal cord we next refer to (Case 2, W — , 
aet. 42 : autopsy showed kidneys granular and contracted ; 
left ventricle of heart hypertrophied ; old liEemorrhagic 
changes in brain, &c.), there are changes (simple exudation) 
similar to the above, but the vessels and connective tissue 
are thickened by fibroid material. In the anterior columns 
especially, some of the fibrils of the connective-tissue plexus 
are thickened by fibroid material, and some of the adjoining 
nerve-tubules are completely concealed, as if they had been 
destroyed by it. There are many small centres of this 
fibroid thickening. Portions of the columns appear healthy, 
but the greater part is evidently the seat of morbid change. 
Most of the connective tissue is free from the fibroid 
thickening, but granular matter is exuded along its fibrils, 
or the fibrils themselves are swollen by exudation. There 
are collections of hasmatin granules in one of the posterior 
columns, also showing exudation. Together with these 
changes there are numerous masses of homogeneous (stained) 
material, mostly spherical in shape. Their outline is not 
well defined. Their substance seems diffused amongst the 
nerve-tubules and connective tissue. In portions of the 
column these masses are very numerous. Here and there 
they are more circumscribed, and they have the appearance 
of being bounded by a very thin wall, suggesting that the 
material is accumulated within a nerve-sheath, and distends 



398 DISEASES OF THE VASCULAR SYSTEM. 

it. Owing to the accumulation of this exudation, the 
connective-tissue fibrils, instead of forming thin partitions 
between the nerve-tubules, as in healthy cords, appear spread 
out, rendering the nerve-tubules very indistinct. They 
appear to be embedded in a granular homogeneous substance. 
Some of this substance could be directly traced as effused 
from the vessels, for in one part of a section a vessel is seen 
cut across, and surrounded by hyaline homogeneous (dyed) 
material. Some of the arterioles of the dorsal portion 
are very noticeably thickened by fibroid material, and it 
was particularly observed that whilst the tunica intima of 
one of them is normal, and some of its transverse muscle- 
cells normal, other muscle-cells are indistinct, as if much 
shrunken ; and outside the muscle layer there is a homo- 
geneous substance bounded by coarse and dense-looking fibres, 
amongst which are spindle-shaped nuclei. In some of the 
larger arterioles the muscle-cells appear larger than normal 
(hypertrophied ?), but in other parts of the same vessel they 
are apparently atrophied and reduced to mere granules. 
The walls of some of the capillaries look simply coarse, but 
others are evidently much thickened, for the walls of some 
are thicker than the diameter of their lumen. 

The above details denote chronic changes in the arterioles, 
capillaries, and connective tissue, with recent exudation. 

We may now refer to one more cord (Case 3, of Ann C — , 
set. 52 : autopsy showed granular contracted kidneys ; dilated 
hypertrophied left ventricle ; atrophied skin and spleen ; 
arterial disease), in which there are morbid changes resem- 
bling those above. The adventitia of the arterioles is thick- 
ened and coarse, with here and there an excess of elongated 
nuclei in it. The walls of some of the arterioles have a 
hyaline appearance also. Much of the connective tissue 
seems abnormally rigid and coarse, and, as in the two other 
cords referred to, there are appearances indicating that there 
has been recent exudation between and into the nerve-tubules. 
Therefore a great many of the septula throughout the cord, 
even where they are not markedly thickened, have an ab- 
normally granular aspect ; and in parts, homogeneous mate- 
rial clouds the medullary sheaths and the axis-cylinders, 
whilst there are numerous spherical homogeneous stained 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 399 

(colloid) masses, such as were seen in the two previous 
cases. 

The changes in the connective tissue of the above-named 
cords are slight compared with those observed in the cords 
to be now described, and some of the changes are so minute 
that we cannot appreciate them by the lower powers of 
the microscope, though by comparison with a healthy cord 
and under higher powers the changes are very obvious. 
The fibroid thickening in the adventitia of some of the 
vessels (W — and C — ) indicate chronic change, though 
the very large quantity of homogeneous and very finely 
granular material scattered largely through these cords, is 
regarded as the product of recent serous exudation. We 
were led to this opinion from the appearance and arrange- 
ment of the material itself in these cords, and from other 
facts which have come under notice. 

We have already stated that a very large portion of this 
homogeneous and granular material is diffused through the 
cord-structures, without any abrupt margin ; but some of it 
is sharply bounded, not apparently by any new structure, 
but by being moulded to the outline of a tubule ; but it is 
conceivable that the boundary around some of it may have 
been the wall of a lymphatic vessel, presuming such vessels 
exist in the cord. These so-called colloid bodies are 
probably, as we have said, but simple exudations of albu- 
minoid material. Similar hazy, homogeneous material, we 
have found, more or less hyaline, but in very much smaller 
quantity, in parts of a healthy cord ; for instance, in that of 
a boy suddenly killed. If it be albuminoid matter the 
product of simple serous exudation, it might be expected that 
it would be found in minor degree, even in healthy cords, 
especially where death occurs rapidly by injury ; for if the 
body be well nourished, then, especially during very rapid 
dying, the venules and capillaries of the cord, as of other 
organs, must be abruptly and unduly distended as the pul- 
monary circulation is suddenly arrested ; consequently serum 
escapes more or less from the distended vessels into the 
substance of the cord, livei", kidney, and other organs. 
Microscopical examinations of the oi'gans of persons acci- 
dentally killed in health, teach that at one time serum alone 



400 DISEASES OF THE VASCULAR SYSTEM. 

escapes, at another serum together with leucocytes, with or 
without red corpuscles. But neither in healthy cords, nor 
even in all cords from cases of Bright^s disease, have we 
seen such large and well-defined collections of granular and 
homogeneous material as observed in the three cords above 
described. Again, to show that these homogeneous collec- 
tions hitherto called colloid masses are sero-albuminoid 
exudations, we may state we have observed, where the brain 
substance has been contused by accident, as in fractured 
skull, that similar masses are scattered in very large quantity, 
and similarly diffused into and amongst the nerve-elements. 
For instance, sections of the pons and medulla oblongata 
taken from the body of a healthy young man, killed by 
fracture of the base of the skull, more especially of the 
pons, were thickly studded with an enormous quantity of 
these homogeneous masses, and here and there heematin 
granules. Again, where the cord has been injured by 
fracture of spine, we have found these homogeneous masses 
in very great quantity in the cord substaiice. Further, in 
cases of acute paraplegia (myelitis) a large quantity of this 
homogeneous material is found lying around the vessels, 
and disseminated from them into the surrounding structures, 
with increased nuclei and leucocytes. 

From these facts, together with the appearance and ar- 
rangement of these colloid masses, we are led to regard them 
as merely albuminoid exudations, the water of which has been 
removed in course of preparing the sections ; and the very 
ready way in which the material takes dye, tends to show, 
as we have already once remarked, that it was at the time 
of death plastic. It is, moreover, to be noticed that there 
is not with such exudation a great increase of the nuclear 
bodies, or corpuscles, to indicate that the exudation is inflam- 
matory. Still it is in much greater quantity than is found 
in the mere passive congestion of healthy cords. We are, 
therefore, led to conclude that this condition is simple 
oedema of the cord, coincidentally, it may be, with oedema 
of other parts of the body. Naked-eye examinations show 
that the membranes of the cord, especially of the lumbar 
region, are not infrequently oedematous in cases of inter- 
tubular nephritis. In giving this account of these bodies 



I 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 401 

we ought to state that somewhat similar colloid masses 
may, as is supposed, be produced by dissolution of uerve- 
tubules. 

We may now pass on to describe morbid changes more 
marked and more advanced. 

First there is thickening of connective tissue by broad 
stream -like collections of hyaline homogeneous substance, 
this being in such amount as to compress and invade the 
nerve-tubules, so that the axis-cylinders are destroyed or 
invisible. Such a condition is more than mere oedema, but 
still short of actual myelitis. Secondly, there follow exuda- 
tion and multiplied connective-tissue nuclei and leucocytes — 
myelitis. 

In Case 4/ in the dorsal portion of the cord the connec- 
tive tissue is seen much thickened by a homogeneous 
substance, studded with an excess of nuclei, clustered in 
parts into twos and threes ; the walls of some of the arteri- 
oles and capillaries ai^e much swelled and markedly hyaline ; 
their outline is partially concealed by this hyaline (dyed) 
homogeneous substance, which infiltrates the surrounding 
connective tissue, and spreads away from the arterial wall 
amongst the surrounding nerve-structures. (See Pis. X 
and XI.) 

This homogeneous (dyed) substance extends into some of 
the medullary sheaths, but the axis-cylinders appear to a 
great extent unaffected, though some seem invaded by it. 
It is also very noticeable that there is increased nuclear 
formation in the grey matter. Together with these recent 
changes, there are also indications of chronic thickening by 
a fibroid substance of the adventitia of the arterioles. The 
muscle-cells in some arterioles are inappreciable. 

In the columns of cord of another case (Case 5 ^) there is 

^ Case 4, of James B — , set. 47. Autopsy showed granular contracted 
kidney, with indication of recent acute nephritis ; emphysema ; dilated and 
hypertrophied left ventricle; great contraction and granular condition of 
mucous membrane of stomach ; atrophied brain. Pericarditis and pneu- 
monia. 

- Case 5, of William Geo. H — , ret. 69. Autopsy showed simple fracture 
of femur ; granular contracted kidney ; hypertrophied heart, weighed 
18 oz. Lungs emphysematous ; pleuro-pneumonia at base of one. Atrophied 

26 



402 DISEASES OF THE VASCULAR SYSTEM. 

similar evidence of myelitis and indications of chronic change. 
The connective tissue of the columns of the lumbar portion 
is thickened throughout with an excess of nuclei. This 
thickening is largely produced by an exudation of granular 
and hyaline homogeneous (dyed) material in and around the 
the connective-tissue nuclei and fibrils. The connective- 
tissue nuclei are increased or leucocytes aggregated. Also 
spherical bodies (colloid masses) are scattered here and there. 
Some vessels (arterioles) are much thickened, their walls 
even thicker than their lumen, and nearly all have the cha- 
racteristic hyaline appearance. 

The outline of some of the arterioles is coarse, with 
spindle-shaped nuclei scattered along it, but these are seem- 
ingly not in any decided excess. The connective tissue 
extending between nerve-tubules from the adventitia of some 
of the arterioles is markedly thickened by felt-like and 
homogeneous substances. These appearances seem to denote 
that the vessel walls and the connective tissue of the cord 
are thickened by some chronic fibroid change as well as 
swelled by some recent exudation. 

Another very striking feature is the puckered condition 
of the surface of this cord. At the depressed parts tracts 
of thickened connective tissue extend from the surface into 
the substance of the columns. In reference to this condi- 
tion we may remark that though in healthy cords there is 
usually slight depression, where the vessels pass in at the 
surface, yet the contrast between the abnormal puckering- 
above described from thickened connective tissue, and that 
which normally occurs, is striking. In these thickened 
fibroid tracts are arterioles, in the thickened walls of which 
is an excess of nuclear bodies. The connective tissue about 
the posterior roots especially is much thickened, and also 
contains a great number of nuclear bodies and homogeneous 
colloid masses ; and the surface of the cord corresponding to 
this part is still more abnormally puckei'ed and uneven. This 
fact of irregular puckering and contraction, associated with 
thickened connective tissue, seemed to us so important that, 

spleen, with thickened connective tissue. Atropliied brain. No cDdeina. 
No indication in kidney of acute nephritis. 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 403 

before determining that it had a pathological value^ a care- 
ful comparison was made with healthy cords. 

The changes in the above-named cords are distinct, how- 
ever much difference of opinion there might be as to their 
significance, but they seem small in degree when compared 
with the changes we now come to. 

In the dorsal poi'tion of the cord of Case 6,^ but most of 
all in the posterior columns, the connective tissue almost 
throughout the white matter is enormously altered. The 
septula and their finer processes are replaced by a dense 
homogeneous substance. This new material, which has taken 
dye well, is studded with many large (swelled ?) nuclei. 
These are in great excess, and aggregated into small groups 
(see PI. XII). In the posterior columns this dense substance 
is in greatest quantity. Many tubules are embedded in it, 
and their axis-cylinders only seen. Others would seem to 
have been entirely replaced by the exudation. But even 
where this material occurs in greatest quantities, some 
medullary sheaths and axis-cylinders, even in its vicinity or 
surrounded by it, remain almost normal. The arterioles and 
capillaries are seen very greatly thickened by homogeneous 
or faintly fibroid material. Capillaries and very fine arte- 
rioles with much thickened walls are seen surrounded by 
great quantities of this same material, which radiates into 
the surrounding connective tissue, compressing and invading 
the nerve-tubules (see PL XVIII). 

We now come to what seem to us more chronic changes. 
In the optic thalamus in Case 7" there is fibroid thickening, 
forming a kind of scar, embedding hgematin crystals, evi- 
dently the remains of old haemorrhage. The septula of the 
cord in this case are much thickened by a fine felt-like sub- 
stance. The changes here seen recall to our minds that the 
French pathologists have described similar fibroid thickening 
in tracts of the cord in cases of old cerebral haemorrhage, and 

' Case 6, of Henry G — , agt. 36. Autopsy showed dilated hypertropLied 
left ventricle ; atrophied brain ; syphilitic changes in liver (?) ; kidneys 
simply venously congested. 

^ Case 7, of T — . Autopsy showed old haemorrhagic changes in the 
form of ochrey matter in the corpus striatum, recent blood-clot in the one 
hemisphere ; dilated hypertrophied left ventricle ; granular kidneys. 



404 DISEASES OP THE VASCULAR SYSTEM. 

called it " descending sclerosis/^ The morbid growth in 
this cord had destroyed many of the medullary sheaths and 
axis-cylinders. 

In another case (Timothy K — ^) the chronic fibroid change, 
though very marked, was confined to numerous small areas 
of the columns {sclerose en plaques). In the dorsal portion 
of the cord, the part principally examined, there is much of 
this morbid change, but it is greatest near the surface of 
the cord in the vicinity of the posterior roots. Even with 
half-inch objective the connective tissue seems to be here 
and there much thickened, though there is a good deal of 
healthy nerve-structure remaining. It is one of the most 
noticeable features of this cord that the connective-tissue 
nuclei are surrounded by a quantity of fibroid material, as if 
they were centres of this thickening. Such is the interpre- 
tation we adopt. Examining this new material further 
( X 250), the nuclei are seen well stained and apparently 
swelled, and extending from them is an exceedingly delicate 
felt-like substance, spreading out and invading and destroying 
adjoining nerve-tubules ; though in the vicinity of these 
destructive processes there are normal axis-cylinders and 
medullary sheaths (see PI. XIII) ; the connective-tissue 
plexus between them has a coarse appearance. In some 
parts both connective tissue and nerve-structures seem 
normal. This is especially so in the lateral columns. This 
new matei'ial is not homogeneous, as we have already said, 
but seems to be made up of extremely delicate fibrillse, 
which can be best expressed as felt-like. Many axis-cylin- 
ders appear abnormally large (hypertrophied ?). Some of 
the arterioles and capillaries are surrounded by a large 
quantity of new (felt-like) material ; some are seen to be so 
much thickened that the thickness of their walls is double 
that of the lumen. The hyaline appearance is well marked. 
There are a number of homogeneous (colloid) stained bodies 

' Case 8, of Timothy K — , aet. 43. Died November 22nd, 1875. Autopsy 
showed brain convolutions much atrophied ; vessels atheromatous. Heart 
■weighed 20 oz. ; left ventricle dilated and hypertrophied ; valves normal ; 
lymph on pericardium. Lungs collapsed at bases. Kidneys small and 
granular, weighed 35 oz. each. Liver and spleen healthy. Muscular 
atrophy well marked in muscle of thumbs and interossei and muscle of 
forearms. 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 405 

scattered over the section. These are very noticeable 
objects in the centre of the thickened masses. 

Tracing further these chronic changes, we may describe 
next the alterations seen in Case 9.^ In the anterior 
columns, and especially near the posterior roots, but in other 
parts also, the connective tissue is much thickened. Many 
small foci of thickening are seen as in the preceding case, 
and in the centres of these are nuclei, with much fibroid 
material around them, and in many parts where this has accu- 
mulated the nerve-tubules cannot be distinguished, or only 
the axis-cylinders, which are so shrunken as to be scarcely 
recognisable. With these changes there is still a great 
deal of healthy nerve-substance. Arterioles and capillaries 
in this cord are also much thickened by fibroid material. 

We now adduce evidence of more advanced and more 
extensive fibroid changes in cord — diffused sclerosis. 

We take a case (Case 10) in which there was progressive 
muscular atrophy and distinctive cardio-renal changes.^ In 
the dorsal portion of the cord there is extensive inorbid 
change, more especially in the posterior and lateral columns. 
The larger septula near the periphery are much widened, and 
it seems evident that the thickening has extended from the 
surface inwards. Some of these septula are three or four 
times thicker than normal ; this increased thickness is 
produced by fine (felt-like) fibroid substance, without large 
nuclei. From each side of these widened septula thickened 
branches of fibroid material are given off ; and in some 
places near the surface these are so broad that they seem 
to have coalesced and formed au uniform mass of fibroid 
substance, in which scarcely a nerve-tubule can be seen 
(see PL XV). In other places the thickened branches have 
not coalesced, but the growth has extended thickly round 
the nerve-tubules. Here and there is a normal nerve-tubule 
embedded in this fine felt-like thickening ; or the medullary 

> Case 9, of James C — , aet. 56. Autopsy, February 5th, 1874. Dilated 
and hypei-trophied left ventricle, heart weighed 22 oz. ; no valvular disease ; 
suppurative nephritis ; brain very slightly atrophied. 

* Case 10, of William S — , set. 40. Autopsy, March 17th, 1873, showing 
muscular atrophy ; granular contracted kidney ; indication of acute nephritis ; 
dilated hypertrophy of left ventricle ; no valvular disease nor adherent peri- 
cardium ; brain slightly atrophied. 



406 DISEASES OP THE VASCULAR SYSTEM. 

sheath may be gone, leaving only the axis- cylinders ; or 
there is no decided trace of nerve-tissue remaining, being 
replaced by this new j&broid material. At a little distance 
from the surface of the cord, these very broad septula have 
their fibrillar ramifications replaced by broad lines of homo- 
geneous or fine felt-like substance, surrounding each nerve- 
tubule. Nerve-tubules are seen embedded in ring-like 
masses of this substance (see PI. XIV). It is instructive to 
notice that in some parts there are numbers of connective- 
tissue nuclei scattered as in healthy cords. They are well 
stained, but there is a much larger amount of protoplasm 
than normal around them. It is further noticeable that not 
only has the protoplasm increased around the nuclei, but these 
latter have multiplied. The condition of the grey matter we 
consider undetermined. 

In the most advanced stages of the changes we have thus 
called attention to (Case S — ), broad masses of uniform 
fibroid substance are to be seen completely replacing areas 
of nerve-tubules, and sending' off thick processes of the 
same fibroid material which surround and embed some nerve- 
tubules, and have destroyed others. This is well represented 
in PI. XV. 

Whilst extensive atrophy of the nerve-tubules thus occurs 
with this deposit in some parts, in others the axis-cylinders 
are enormously swollen or hypertrophied. 

The vascular sheaths are also seen surrounded by a large 
amount of the same fibroid substance. 

We adduce two more cases (P — and M — ) where the 
chronic fibroid change was very much advanced. Both ter- 
minated in paraplegia. Sections of the lumbar portion of 
the first (P — ,^ Case ii) show the connective tissue in 
many parts of the white matter very much thickened by a 
felt-like fibroid material. This is especially marked in the 
posterior and lateral columns, but it is present also in 
the anterior columns. The thickening is very irregularly 
distributed, leaving some portions of the columns compara- 

' Case II, of George P — , set. 58. Autopsy showed atrophy of brain; 
vesicular emphysema, with broncho-pneumonia ; kidneys faintly granular ; 
cystitis; spleen small. Heart weighing iijoz. ; left ventricle not hyper- 
trophied. 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 407 

tively healtliy, certainly much less affected. Many of tlie 
septula are extremely thickened by this fibroid substance, 
which extends from them along the course of the connective- 
tissue plexus, invading- some nerve-tubules, rendering their 
axis-cylinders very indistinct (shrunken) or inappreciable. 
Many of these thickened masses send off branches which 
intercommunicate. In their meshes are medullary sheaths, 
seemingly swelled up and disorganised, and the axis-cylin- 
ders scarcely or not at all recognisable (see PI. XVI). 
There is also a cloudy homogeneous material scattered here 
and there, seemingly exudation material, faintly stained ; 
also spherical homogeneous masses, so-called colloid bodies. 
Further, in portions of the fibroid material there are a 
number of spherical nuclei, which appear to be newly-formed 
connective-tissue corpuscles. 

The vessels are greatly thickened, embedded in large 
quantities of fibroid material (see PL XVI). This applies 
to arterioles and capillaries. This fibroid thickening is seen 
extending in great quantities from the adventitia of the 
vessels into the surrounding connective-tissue plexus, clearly 
denoting that the vessels have been centres of thickening, 
and that the fibroid change has radiated from them (see PI. 
XIX). These appearances lead us to infer that the fibroid 
change originated in the posterior and lateral columns 
around vessels and along septula, and that they were chronic 
in character. Many nerve-tubules Avere atrophied or con- 
tracted by the growth ; but there was evidence also showing 
that acute changes had supervened on the chronic, swelling 
and destroying many tubules which had escaped the fibroid 
thickening. 

In the cord we have last to mention (M — ^) the fibroid 
changes are extremely marked, and in the posterior columns 
most of all. A portion of the surface of the posterior 
column is seen to be much puckered, as if drawn inwards 
by fibroid contraction. One of the most striking features 

' Case 12, of Stephen M — , set. 52. Autopsy showed fibroid consoli- 
dation of upper lobes of lungs ; heart, no noticeable change, except some 
dilatation of right side ; fibroid thickening in liver ; testicle smaller than 
normal, tough, firm, and Invaded by fibroid material ; kidneys normal ; spleen 
normal. 



408 DISEASES OF THE VASCULAR SYSTEM. 

of this cord is an extraordinary thickening of the vessels ; 
their intima is sharply bounded ; outside that is a clearer 
stratum, and that again is bounded by the coarse fibres of 
the adventitia, and from it radiates a felt-like fibroid material 
studded with nuclei and granules (see PL XVII). As many 
as thirteen of these thickened vessels are counted in the 
field under Hartnack's objective No. 7, ocular No. 3, but it 
is very difl&cult to determine the condition of much of the 
surrounding connective tissue ; it is studded with granular 
matter and nuclei ; it looks as if it had undergone general 
fibroid change. There appear to be many shrunken axis- 
cylinders ; others look large, either swelled or hypertrophied. 

It is a very striking feature in this cord also, that both 
the connective tissue and the nerve-tubules seem compara- 
tively little affected in some portions of it. But even where 
the changes are in comparison very slight, the fibrils are in 
parts thickened by fibroid material, and scattered amongst 
it are many very small nuclei, and the vessels are thickened 
by fibroid substance. This fibroid change is seen extend- 
ing from the surface in many parts. In one part a broad 
wedge-shaped fibroid mass is traced from the surface in- 
wards right across the field (see PL XVII). Many nuclear 
bodies are embedded in the fibroid substance. As it tapers 
off, thick vessels are observed lying in it. At its summit it 
bifurcates ; one extremity includes three thickened vessels ; 
the other seemingly spreads out, embraces vessels, and a 
network of new connective tissue, consisting of nuclei and 
fine fibrils, extends from around the vessel. This new tissue 
together forms a broad mass with no recognisable nerve- 
structure in it, and occupies about a third of the field. 
Between the two arms just named, a group of nerve-tubules 
is seen, with their axis-cylinders and medullary sheaths little 
altered. There is so much morbid change in this cord that 
we can here only describe some of the most prominent 
features. 

In some of the cords described there was a large quantity 
of dense protoplasm accumulated in and around the vessel 
walls, causing great thickening. This material differed from 
the simpler exudation by its greater density (see PL XVIII) 
and less hyaline character ; by taking dye more readily, and 



CHANGES IN THE SPINAL COED AND ITS VESSELS, ETC. 409 

by the increased nuclear bodies in it. These changes seemed 
to us to denote myelitis more or less acute. 

In other cords the arterioles and capillaries were sur- 
rounded by large quantities of felt-like fibroid material (see 
PI. XIX)j which extended into and between the nerve-tubules. 
Where the connective tissue was much thickened, one or 
more vessels were commonl}^ seen embedded in it. This 
fibroid thickening corresponds to what Charcot, Ley den, and 
others, have named and described as sclerosis, and to what 
E/indfleisch calls " inflammatory induration.'^ Rindfleisch 
says^ " An attentive examination of the smallest of these 
foci leads to the curious discovery that the masses of fibroid 
thickening have all got a red spot or line in their centre, a 

distended blood-vessel All these vessels with 

their finer ramifications are in a state which we should not 
scruple elsewhere to call one of chronic inflammation.'' 

He particularly refers to the increased cells thickening 
the adventitia of the arterioles and capillaries, which, as we 
also have stated, is seen more especially in the acuter 
changes, and he goes on to remark, " In these alterations 
of individual vascular tufts I see the first anatomical 
element of the disease ; the second consists in a fibroid 
metamorphosis and overgrowth of the neuroglia." 

Our observations on the cord show that exudations from 
the vessels lead to swelling and thickening of its perivas- 
cular and other tissues. This is acute in some cases ; in 
others the change is much more chronic. Not only is there 
in the acute cases the traceable exudation from vessels 
evidently causing the surrounding thickening, but in the 
chronic cases also the large collection of fibroid material 
around the arterioles and capillaries, becoming thinner and 
thinner as it recedes from them, supports the opinion that 
the fibroid change begins in and around the walls of the arte- 
rioles and capillaries. 

We have not yet, however, arrived at any conclusion as 
to whether there is merely an excessive discharge of blood- 
plasma, or whether the plasma accumulates because the lym- 
phatics are blocked, or the connective-tissue cells or areolae 
thickened, blocking and preventing the plasma passing on- 
wards into the lymphatics. In whatever way it happens the 



410 DISEASES OF THE VASCULAR SYSTEM. 

plasma accumulates most probably j&rst around the capil- 
laries^ tben in the capillary wall^ and as the obstruction 
there is increased, the tension is transmitted backwards, and 
exudation into and around the arteriole wall follows as a 
consequence. In support of this statement Rindfleisch 
notices, as we have done, that the calibre of the affected 
arterioles seems increased. 

Having thus described the changes we have observed in 
these cords, it remains to summarise our conclusions. 

1. In two cases (H — and B — ) with granular and con- 
tracted kidney there were no appreciable changes in the 
cord ; in two others (D — e and D — n) the arterioles and 
capillaries of the cord were hyaline and much thickened. 
[The details of these cases are here not introduced.] 

2. In one case (L — ), in which there were granular con- 
tracted kidneys (with indications of recent acute nephritis) 
and well-marked hypertrophied heart, there was seemingly 
exudation into the cord substance (oedema). 

3. In two cases (W — and C — ) in which there were the 
usual changes of chronic Bright's disease with contracted 
kidney (heart hypertrophied, kidneys contracted), some arte- 
rioles and capillaries of the cord were thickened by fibroid 
material, with or without hyaline appearance ; others were 
swelled and hyaline only. The connective tissue in parts 
looked rigid, and there was exudation material around and 
into it and the nerve-tubules — fibroid change and oedema. 

4. In another case (W — ) no traces of chronic fibroid 
changes were found in the arterioles and capillaries, but their 
walls were greatly swelled by exudation of homogeneous hya- 
line material, which extended in broad tracts from them into 
the surrounding tissues (initial myelitis ? hypostatic ?). 

5. In three cases (H — , F — , and B — ) some of the 
arterioles and capillaries were much thickened, their walls 
swelled by hyaline material, and without any or but doubtful 
evidence of chronic fibroid changes in them. The connective 
tissue was swelled and the fibrillar character lost, seemingly 
in consequence of large exudation of hyaline homogeneous 
material into it. Its nuclei were multiplied (myelitis). But 
whilst the condition of some of the ai'terioles and capillaries 
and the connective tissue and nuclei was thus changed. 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 411 

there were other arterioles apparently thickened by coarse 
fibroid material, indicating- more chronic changes preceding 
the acute. 

6. In two cases (K — and C — ) arterioles and capil- 
laries were here and there thickened by fibroid changes, and 
there were numerous centres of thickening of connective 
tissue with atrophy or contraction of nerve-tubules, whilst 
in many other parts the cord substance looked strikingly 
healthy {sclerose en plaques). In one of these cases (C — ) 
the brain was atrophied ; the heart was greatly hypertrophied, 
weight twenty-two ounces, valves healthy ; kidneys venously 
congested, and with indications of only a little recent 
suppurative nephritis, excited by the jaaraplegic cystitis. In 
the other case (K — ) the kidneys were granular and con- 
tracted ; heart hypertrophied ; no valvular disease. 

7. In three cases (S — , P — , and M — ) the arterioles and 
capillaries were much thickened by fibroid material, and 
sections of these vessels showed them embedded in large 
quantities of felt-like fibroid substance, which extended from 
them, dividing and subdividing, and invading and destroying 
medullary sheaths and axis-cylinders, or enclosing other 
nerve-tubules in a coarse felt-like connective tissue. Near 
the exit of the posterior nerve-roots from the surface of 
these cords the connective-tissue thickening was especially 
great, and many nerve-tubules at this part were replaced 
by fibroid material (diffuse sclerosis). 

It may be superfluous to repeat that, notwithstanding the 
destructive changes we have described in these cords, a 
considerable portion of their structure remained compara- 
tively healthy, and that fact elucidates some of the pecu- 
liarities of the clinical features observed in these cases. 
From the detailed particulars of the arterioles and capil- 
laries it may be inferred that the walls of some were simply 
swelled up by hyaline albuminoid material, without much 
increase of the nuclei of the intima or adventitia in number ; 
and in referring the changes observed in the cords of L — 
and W — to simple exudation, we are unable, from the 
appearance of the cord and exuded material, to determine 
to what extent it occurred shortly before death, during 
dying, or even after death. In the case of L — there 



412 DISEASES OF THE VASCULAR SYSTEM. 

was general oedema in connection with acute nephritis ; 
the exudation into the cord-substance might therefore be 
part of the general serous accumulation. In the case of 
W — there was no renal disease and no genei'al oedema. 

The hyaline material had, in W — ^s case, spread widely 
into the textures of the cord ; here and there stream-like 
extensions disintegrating the cord-substance. The con- 
nective-tissue nuclei seemed altered, but it might fairly be 
questioned if they were increased in number. These appear- 
ances seemed to us to indicate that the exudation had most 
probably occurred during the venous congestion of dying, 
and may be even, to some extent, after death. We still 
think it most probable such was their origin. We have to 
qualify this, however, by stating : (a) That we have not found 
a similar amount of exudation of hyaline material in healthy 
cords of persons killed, but in a minor degree we have found 
this hyaline swelled appearance in the connective tissue of the 
cervical cord of a man killed by fractured skull and lacerated 
brain (B — ). It was instructive to notice that then the 
appearance was less marked in the dorsal cord, leading to the 
inference that the exudation and swelling were due to the 
injury to the head. (b) That we have not found similar 
exudation either in amount or manner of arrangement in 
most cords diseased, (c) That we have seen similar exuda- 
tion, but in less degree, in the cord of a person who died 
of tetanus. Here the vessels of the cord were very full 
of blood, and their walls were hyaline, and the connective 
tissue also. 

We are led by these facts to reserve the question of the 
origin of this simple exudation for further examination. 

The fibroid changes observed in several of the cords de- 
scribed resemble those of granular contracted kidney in the 
following features : 

In the spinal cord, as in the kidney, the fibroid change, 
as might be expected, is most marked where the connective 
tissue is most abundant. It extends in the cord, as in the 
kidney, from the surface- membrane inwards; or in the cord 
from the grey matter outwards, and in the kidney from 
the base of the cones inwards : and in both cord and 
kidney it extends from the adventitia of the arterioles and 



CHANGES IN THE SPINAL CORD AND ITS VESSELS, ETC. 413 

capillaries into surrounding connective tissue. The fibroid 
material in the cord, as in the kidney, contracts and com- 
presses surrounding tubules, atrophying or destroying them, 
but leaves many other adjacent tubules comparatively normal. 
In the cord, as in the kidney, it would seem that acute change 
commonly supervenes on the chronic. Seeing that so many 
tubules remain comparatively normal, we are enabled to 
understand how it is that both cord and kidney may retain 
much of their functional activity, even when they are the 
seat of very extensive fibroid change, and this usually con- 
tinues (persons walk or secrete urine fairly well) until the 
more healthy tubules are deteriorated by acute changes. 

It only remains to state that of the five cases in which 
there were well-marked fibroid changes (sclerosis) in the 
cord, in two (S — and K — ) the kidneys were very granular 
and contracted, left ventricle of the heart hypertrophied, 
no valvular disease. 

The kidneys were slightly granular, and the left ventricle 
of the heart not hypertrophied, in one (P — ). 

The kidneys were not contracted nor granular in two ; but 
in one of these (M — ) the lungs were the seat of extensive 
fibroid induration and the testicle also, and in the liver a 
little similar change ; in the other (C — ) the left ven- 
tricle of the heart, without valvular disease, was greatly 
hypertrophied, and the brain atrophied. 

These particulars show that fibrosis in the cord may occur 
coincidently with fibrosis of the kidney ; or it may be in 
advance of the fibroid change in the kidney ; or occur as 
part of a general fibrosis, altogether independently of renal 
disease. 

We cannot conclude these observations without expressing 
our obligations to Mr. Robert Kershaw for the great care, 
patience, and skill with which he bas prepared the sections ; 
to Dr. Turner, for much help in collecting and revising 
details ; and to Mr. Hollick, the artist, for the extreme care 
with which the drawings have been executed. 



414 DISEASES OF THE VASCULAR SYSTEM. 

Note. — In tlie ' Pathological Society's Transactions/ vol. 
xxviij 1877, a paper criticising the theory of arterio-capillary 
fibrosis^ appeared, entitled '' On the Changes in the Blood- 
vessels and in the Kidney, in connection with the Small 
Red Granular Kidney," by George Johnson, M.D. — (Ed.) 



DESCRIPTION OF PLATE VII. 

Plates VII to XIX inclusive illustrate the Observations 
of Sir William Gull and Dr. Sutton on the Changes in the 
Spinal Cord and its Vessels in Arterio-capillary Fibrosis. 
(Pages 391 — 414.) The original drawings were made by Mr. 
A. T. Hollick. 

Plate VII. — Drawings represent sections of a healthy cord, from a boy, 
set. about 14, killed by an accident. 

Fig. I. From the lateral column near the surface and posterior nerve-root, 
showing the fibrillar character of the connective tissue, radiating from 
centres, dividing and subdividing ; its finest branches surrounding the 
individual nerve-tubules in the form of a plexus. In each of these centres, 
where a nucleus is usually seen, there is a quantity of granular matter, but 
the nuclei themselves are not represented. 

a. Faint hyaline cloudiness (albuminoid material ?) seen pervading 
the nerve-tubules in some parts. 

Fig. 2. From the lateral column, near the grey matter, showing — 

a a. Vessels (finest arterioles) cut longitudinally and transversely, from 
the outer coat of which the connective-tissue fibrils extend 
between the nerve-tubules. 
(3. A centre from which the exceedingly fine connective-tissue fibrils 
are radiating, and in which a nucleus is distinctly seen. 

Several other similar centres with the nuclei are represented in the drawing. 



Plate Vn. 



Piq 1. 






^ <i:^J^. ^ 



'..•(• 




i/i, • 















--fe>^ 



^^i^ 



ir i^^ 



-SJ. 



N; 



l?5^ 



'fc^J 



^:^^'iS 













Fig 2. 



^j^. 



-%t 



'aN- 






V.'e.3t,l^ewioaiT. cihrcono. 



DESCRIPTION OF PLATE VIII. 

Drawings represent sections of the healthy cord of a man, set. 20, who 
was killed by an accident. Intended to show the appearance of the connec- 
tive-tissue cells and their radiating fibrils. [The artist has drawn the fibrils 
too coarsely.] 

Fig. I. From the lateral column, close to the posterior cornu, showing — 
a. The floor of a vessel cut longitudinally, its outer sheath remaining, 
from which fibrils of connective tissues are given off. 
/8/3. Connective-tissue nuclei, with a small quantity of surrounding 
protoplasm, from which fibrils radiate, dividing and subdividing, 
enclosing the nerve-tubules, and forming the connective-tissue 
plexus. 
7. Grey matter of the posterior comu. ( X 330.) 

Fig. 2. From the same region of the cord. 

a. An arteriole cut longitudinally, coloured corpuscles occupying its 
lumen. The small amount of perivascular connective tissue 
round it is to be noticed. (X 250.) 



I 



PlsLte "vm. 



Pin ] 















»''»>=^< 
-k^ 




Ficj 2. 



,4.-, 



%:. 



AXHoHicV dal 



"Wffst, TTewina::n. cixrcfccc , 



DESCRIPTION OF PLATE IX. 

Drawings represent sections of the cord of a man, set. 25 (L — ), who 
died with granular contracted kidneys, mottled by acute nephritis ; hyper- 
trophy, with dilatation of the left ventricle. Clinically there was cedema, 
albuminuria, and indications of " uraemia," &c., but no symptoms of spinal 
cord disease are recorded. 

Fig. I. Prom the lateral column in the dorsal region, near the surface and 
the posterior nerve-root. 

rt a. Swollen axis-cylinders. 
y. Granular matter along the plexus of connective tissue, thickening it. 

Fig. 2. Another part of the same specimen. 

/8 p. " Colloid masses," so called, hyaline, homogeneous, (albuminoid ?) 
material. 
y. Granular matter along the connective-tissue plexus, thickening 
and obscuring it. 

These appearances are considered to be due to oedema of the cord. 



Plate IX. 



Tig 1 












(:' 1 a ^ 




330 



A.T.HoUioV. 



Vfeert, NeWTcnaxv cltt'oln.'j 



DESCRIPTION OF PLATE X. 

Drawing represents a section of the cord (lumbar region) of a man, get. 47 
(B — ), who died from pneumonia and pericarditis, with granular con- 
tracted kidneys and hypertrophy, with dilatation of the left ventricle of 
heart. The cord-substance, on section, looked wet — oedematous. No sym- 
ptoms of cord disease noted. The patient walked into the hospital, but 
became comatose shortly afterwards. 

The drawing shows arterioles much thickened, with the nuclei of their 
" intima " multiplied ; and exudation material, which, in escaping, has 
swelled and clouded the vessel wall, and extending from it along the 
connective-tissue fibrils, has swelled and disfigured them also. 
a a. Vessels swelled by exudation. 

/S. Nuclei of intima swollen and multiplied, 
y y. Swollen and deformed connective-tissue nuclei. 
S S. Leucocytes, or connective-tissue nuclei. 

This drawing is considered to represent commencing myelitis. 



T 



Pla^te X 



^■:#.v 



4 



■^ ".. 










.# #■ 



^^^M^ir^^^MM 






ri.^U-izic <lel. 



vV£3t ITewmcLn. chrcnno 



DESCRIPTION OF PLATE XI. 

Drawing represents a section from the dorsal region of the same cord 
(B — ), but showing a more advanced change in myelitis. 
a. Thickened vessel, hyaline layer. 
/3 /3. Thickened connective tissue ; the nuclei multiplied, grouped in 

twos and threes, 
y y. Nerve-tubules invaded (atrophied.''). 

There were also fibroid appearances in this section, but to what degree 
the changes were old we could not determine, because much of the tissue 
was evidently swelled and obscured by recent exudation. 



Plat,e XT 



Y ^. 



•('• 



'lir «; 



:a ' . </'^^ ■.<^>: .A 



^ 



~T- 



4^ 



d : 



% * 






6 





AT HcHicV <1ci. 



"'/fe^l- , N^'-v^na/l (ihram*. 



DESCEIPTION OF PLATE XII. 

Drawing represents a section taken from the lumbar region of the cord of 
a man, set. 36 (G — ), who was admitted with symptoms of loss of co- 
ordination of arms, legs, chest, and articulation. Left ventricle was hyper- 
trophied and dilated, no valvular incompetency. No disease of the kidneys ; 
they were simply congested. The posterior cornua of spinal cord were 
observed to be indistinctly defined, and the posterior columns had a decided 
abnormal appearance. 

The drawing is considered to show still more advanced changes (subacute 
myelitis ?) in the cord. In the previous plate the nuclei are seen for the 
most part small and together, as if dividing ; here they are more generally 
separated and multiplied. With the increasing nuclei large accumulations 
of dense protoplasm are seen (« o) of a more formed appearance, and more 
extensively invading and obscuring the nerve-tubules. 



i 



PlcLte XII 




AXHolUclc del 



"West Newmarv clxramti. 



DESCRIPTION OF PLATE XIII. 

Drawing represents section of the cord of a man, set. 43 (K — ), who died 
with granular contracted kidneys and hypertrophied and dilated left ven- 
tricle. The clinical cord symptoms in this case were those of progressive 
muscular atrophy and paralysis of hands and feet. 

The appearances represented are those corresponding to "sclerose en 
plaques." 

a a. Fibroid thickening around the connective-tissue nuclei, broad 
strands extending from them, contracting and constricting the 
nerve-tubules. 

[The felt-like appeai'ance of the fibroid material is not sufficiently shown 
in the drawing.] 



Plaute XHL. 




^;MI^' :M.zf^^^<m 



A.T.HoHlctiel 



Iflfest iNewttifiai chromo. 



DESCRIPTION OF PLATE XIV. 

Drawing from the cord of a man, set. 40 (S — ), whose spinal symptoms, 
as in the last case, were those of progressive muscular atrophy, and who died 
with hypertrophied and dilated left ventricle, and with kidneys granular 
and contracted, and mottled by acute nephritis. 

The drawing shows still further advanced changes in the connective 
tissue of the cord. The nuclei have mostly disappeared. The intertuhular 
changes (a a) are not so much in amount as in the former plate, but are 
more rigid in character. 



J 



Plctte 'xisr. 






^50 



ATTfonicit ail. 



"'^et.l^evmiaii ehr'oixio . 



DESCRIPTION OF PLATE XV. 

Drawing from the same case as the last plate, representing a section of 
the lateral column, close to the surface and near the posterior nerve-root. 
The appearances shown are those of extreme sclerosis. 

a a. Masses and broad tracts of felt-like fibroid material invading and 
contracting the nerve-tubules. 
/3. Fibroid thickening around a vessel ; its lumen is occupied by 
coloured blood-corpuscles. 

y y. Various gradations of contraction and destruction of the nerve- 
tubules. 



Plate XV. 






^^ 



^M^' 



■■■--( 






.»■ v.- . -^ \ » ^ •- 



r\ ,/Jn 




■''■-^-v/C; 4-'^.?ai^V ' ■'' 



•; 4:>"-\ 



■f-50 



AT.Hollick del. 



Wisei xTevjwvaJn. oKx^amo 



DESCRIPTION OF PLATE XVI. 

Drawing represents section from the cord of a man, set. 58 (P — )> with 
symptoms indicating acute softening of cord supervening on slow failure of 
motor power in legs, accompanied by pains and twitching in the legs. At 
the autopsy the cord appeared normal (?) ; the heart healthy ; kidneys 
slightly granular ; lungs emphysematous. 

The part shown is in the lateral column, near the posterior nerve-root, 
and close to the surface, presenting acute changes upon extreme sclerosis. 
a. A vessel thickened by fibroid material. 
)3/3. Extreme fibroid, felt-like thickening, which has invaded and 
destroyed the nerve-tubules. 
y. Destruction of the nerve-tubules in many parts, 
Sd. Nerve-tubules swollen and seemingly disorganised (acute soft- 
ening ?). 



Plate XYI. 









* 



^i 



.M 



-'fW^r 






€ 






-^ 






to 



'A- 



A.T.Hollick del. 



"V*fi*st l^ev/maJrv clrufTTno. 



DESCRIPTION OF PLATE XVII. 

Drawing represents section from the cord of a man, aet. 52 (M — ), a 
paraplegic patient, who had also paralysis of the sphincters. After death 
extensive fibroid consolidation of the lungs was found and fibroid degenera- 
tion of the testes. The cord was soft in the upper dorsal region, but this 
was attributed to crushing in taking it out of the body. The heart and 
kidneys were normal. There was a history of syphilis thirty years pre- 
viously, and of a fall on the back seventeen years before death, followed in 
a short time by incomplete and temporary paraplegic symptoms in arms and 
legs. He recovered, and followed his employment for seventeen years, and 
then the fatal paraplegia supervened. 

In the larger drawing a broad, wedge-shaped tract of dense fibroid thick- 
ening is seen extending inwards from the surface, and other tracts of similar 
tissue around the vessels in the posterior column. 

a. Region where the nerve-tubules have been destroyed. 
j8 /3. Arterioles greatly thickened. 
S S. Capillaries thickened. 

The smaller drawing represents a group of thickened arterioles, and capil- 
laries from a part nearer to the grey matter. 



pioLte xvn 









m 



'.i^^' 



— 1^ 
— ^ 



/3 -5 5 



O: ' ^'- -as 



•T.Hollick iJ. 



Tfest.TMewjnan ahromo 



DESCRIPTION OF PLATE XVIII. 

From the same case as Plate XII (Gr — ). The drawing is intended to 
show the great accumulation of dense protoplasm surrounding the arterioles 
and capillaries {a a), and extending from them along the tracts of the 
connective tissue, thickening it. 

The specimen is stained with aniline black, which does not show the 
connective-tissue nuclei, which are conspicuous in the former plate re- 
ferred to. 

aa. Arterioles and capillaries filled with coloured blood-corpuscles. 
j3/3. Dense masses of protoplasm thickening the vessels and extending 
from them. 



Plate XVm 




ISO 



HoUicV; lUl 



Went Nt-wraaan c\- 



DESCRIPTION OF PLATE XIX. 

From the same case as Plate XVI. Fibroid, rigid, felt-like material is 
seen surrounding the arterioles, thickening their walls, and extending from 
them in tracts along the course of the connective-tissue fibrils Plate XVIII 
shows that dense protoplasm collects and thickens the vessel walls, and that 
the tliickening radiates from the arterioles and capillaries in the course of 
the connective tissue. Here is shown (in Plate XIX) a more advanced 
change than that represented in previous plate, a stage of sclerotic con- 
traction beginning around the vessels. In other parts of this section the 
contraction is extremely advanced (see Plate XVI). 



PlgL^eXIX 



1/5 ^f^- * • I 






->r'\ \*;>. 




/6£ 



ATHbUick adL. 



Wtst,,N«V7m«2i aitto 



DISCUSSION ON THE RELATION 

or 

EENAL DISEASE TO DISTUHBANCES OF 
THE GENEEAL CIRCULATION, 



ALTERATIONS IN THE HEART AND BLOOD- 
VESSELS.^ 



The above thesis does not obviously raise the question of 
names as to what is or what is not Bright's disease. It does^ 
however, challenge the long-pi-evalent views that the dis- 
turbances in the heart and general circulation occurring 
with renal disease are due to it. Of course there are to be 
eliminated all the cases of primaiy valvular and similar 
mechanical conditions of the circulatory sj^mptoms, generally 
admitted to have an origin quite independent of kidney dis- 
ease, and leaving on one side cures of accidental albuminuria 
which thus arise. 

Before proceeding to read the few condensed remarks we 
have put together, we will put in the forefront the abstract 
of our views, viz. — 

I. Kidney disease is associated with or causes changes in 
the circulation, heart, and blood-vessels variously, according 
to the kind and seat of the morbid changes 'in the renal 

1 By Sir William Gull, Bart., M.D., F.R.S., and H. G-. Sutton, M.B. 
Eeprinted from the ' Transactions of the International Medical Congress,' 
London, 1881, vol. i, p. 374. 



416 DISEASES OF THE VASCULAR SYSTEM. 

tissues, e. g. vascular (arterial or venous) or tubular or 
mixed (parenchymatous nephritis). 

2. Kidney disease may be dependent upon causes pri- 
marily weakening the circulation, e. g. causes of general mal- 
nutrition, phthisis, fever, scrofulosis, alcoholism, syphilis, &c. 

3. Defective renal function has a weakening influence on 
the circulation and nutrition ; tissues become choked by 
oedema, enfeebled by anaemia and iTrtemia, and generally 
wasted, e. g. mottled or large white kidney, surgical kidney, 
&c. 

4. Kidney disease may be dependent upon causes primarily 
leading to thickening of heart and blood-vessels generally, 
and to obstruction of the interstitial circulation through 
the several tissues, e. g. arterio-capillary fibrosis, climacteric 
changes. 

5. The question as to the effects of kidney disease on the 
circulation may often with advantage be reversed, namely, 
as to what is the influence of alterations in the circulation 
in producing kidney disease : e. g. abnormal venous tension, 
arterial tension. 

6. Many of the changes in organs, hitherto considered 
uraemic, are referable to tissue changes, capillary and inter- 
stitial, atrophic, anaemic, effusive, fibroid, &c., and may be 
independent of defective renal excretion. 

Kidney function can only be understood through the phy- 
siology of the general circulation ; kidney disease can only be 
known through the disturbances in the general circulation. 

Clinical and anatomical facts show that the disturbance 
in the general circulation associated with, or dependent on, 
kidney disease, varies according to the kind of morbid change 
in the kidney ; for instance, the disturbance in cases of sup- 
puration of the kidney, (i) "surgical kidney,^' is altogether 
different from the disturbance in cases of (2) 'Marge white 
kidneys " or (3) granular contracted kidneys. 

The antecedent conditions of kidney disease, as in cases of 
scrofulous pyelitis, lardaceous disease of kidney, or large 
white kidneys, cause of themselves disturbance in the general 
circulation — as, for instance, in phthisis, syphilis, abuse of 
alcohol, fevers, heart disease, &c. ; and when from these the 
kidney disease supervenes and increases there is additional 



EENAL DISEASE. 417 

disturbance from that source in the general circulation. 
How much of the whole disturbance is due to the primary 
causes, and how much to the secondaiy kidney disease itself, 
is an exceedingly difficult problem ; the actions and reactions 
may be considered until the answer is in many cases reduced 
to this paradox, that the disease is local hecause it is general, 
and general hecause it is local. 

Kidney disease may be grouped into tubular, vascular, and 
mixed forms ; in mixed, both tubular and vascular structures 
are about equally affected. This latter is the common form. 

I. — The tubular, in its most traceable form, is seen in '^ sur- 
gical kidney,'^ or in strumous pyelitis. The morbid changes 
extending from the pelvis along the tubules to the cortex. 

There is retained excretory matter, and a pathological 
experiment is thus performed, showing the effect of such 
retention on the general circulation. 

There is often ultimate decomposition in the organic 
matters of the excreta into ammonia and carbonic acid, and 
an extreme poisoning of the system. 

It is thus clear what kind of disturbance is produced in 
the general circulation, when excretory matters are poison- 
ously retained. There is not oedema, nor symptoms of uree- 
mia, so called ; little or no vomiting, little or no dyspnoea, 
and no cardiac hypertrophy. There is increasing failure of 
nervous and muscular energy ; the pulse and heart become 
feebler, mucous membranes become hypersemic and catarrhal, 
consciousness remains clear, and there is yellowness of skin, 
denoting change in blood-corpuscles. 

II. — In cases of '^ intratubular nephritis," glomerular or 
other, there must of course be disturbance in the vascular 
system of kidney congestions and exudations, and in many 
cases more or less fibroid intertubular change, so that these 
are often inseparable anatomically from the mixed group. 

But it is useful here to consider the intratubular cases in 
their simpler form, without fibrosis and without cardiac 
hypertrophy, so as to estimate what disturbance occurs in 
the general circulation when the water function of the kid- 
ney fails. 

These cases are characterised by great disturbance both 
in the general vascular and general interstitial circulations. 

27 



418 DISEASES OF THE VASCULAR SYSTEM. 

Speaking generally, in these intratubular cases, the urine, 
at the outset of the disease especially, is diminished day 
by day, but weeks usually thus elapse before there is any 
marked oedema. The skin after awhile becomes puffy, the 
breath short, the nervous system much disordered, &c. 

Failure of water function of kidney does not cause marked 
oedema, until the skin and lung water functions fail also. 

It is an induction from clinical and anatomical facts, that 
as the outflow of water from the kidneys lessens, cseteris 
paribus, the water increasingly accumulates in the inter- 
stitial tissues, lymphatic spaces, and serous cavities : with 
this increased hydrsemia the arterial tension is raised, and 
there is increased tension in skin and lungs ; breathing 
becomes more difl&cult, skin becomes choked with serous fluid 
(oedema), and ultimately air cells and bronchi filled with 
serum (oedema of lungs), or may be of pleura. 

As aspiration of chest (inspiration) lessens, the venous 
circulation is obstructed and the right heart over-distended. 
As the luugs are choked by serous fluid, the air circulation 
in blood and interstitial tissues is hindered, less air being 
inspired, the water (blood) circulation diminishes and gradu- 
ally ceases, since the evaporation of air from the venous 
blood is itself a factor in the blood movement. For it 
cannot be overlooked that gases in a fluid being less affected 
by gravitation, and their particles, especially under the 
circumstances, being more prone to separate from those of 
the fluid itself in which they are contained, they would con- 
cur with the circulating force as against the inertia of the 
fluid itself. Anasmia supervenes and increases, indicating 
that oxidation is diminished, and that less heat is produced. 
It is here to be remarked that air being much lighter than 
water, it is more easily responsive to heat than water ; more 
quickly expanded and compressed ; whilst water, being more 
easily controllable and incompressible, dissipates energy less 
quickly ; it is adapted to store more ; it may consequently 
be inferred, and it is demonstrable, that in the general cir- 
culation there is an auxiliary action and mutual dependence 
between these two mediums, the water and the air circulation, 
and that as one fails, the other fails. 

An increasing anaemia is the worst sign ; it reveals that 



RENAL DISEASE. 419 

heat and light energy have greatly diminished in the circula- 
tion, and that the normal protoplastic operations in the pro- 
duction of the hlood-corpuscles are failing. 

The sense organs, lungs, red corpuscles, and locomotive 
organs are, in the course of animal life, correlatively and pro- 
portionately developed ; and they correlatively and propor- 
tionately fail, as in phthisis and Bright's disease. 

With the failure of the water and of the air circulation, 
there is disturbance in the nervous system ; partly due to 
oedema and anaemia of sense organs ; skin, retina, spinal 
cord, brain, &c. 

It can be shown that there is local disturbance in the 
interstitial circulation of cerebro-spinal system, coincident 
at least with the so-called uremic symptoms ; albumenoid 
and corpuscular exudations, swelling of nerve tissues, &c. 

It is common experience also that the tissues — mucous 
membranes and others — swell through oedema, and become 
additionally swollen by inflammatory exudations ; and life 
is thus ended by pericarditis, peritonitis, pneumonia, mye- 
litis, &c. 

Taking a wide survey, it is clear that the special and the 
general functions fail coincidently ; that as the special water 
function of kidney, lung, and skin fails, the water function 
of the general protoplasm (connective tissues, capillary walls, 
&c.) fails also ; that as the air function of lung fails, the air 
circulation of interstitial tissues fails also. 

Of these cases of intratubular nephritis, it is here to be 
noticed that their antecedents, viz., phthisis, heart disease, 
abuse of alcohol, syphilis, &c., bear witness in themselves 
that there is primary failure of nutrition throughout the body 
in the protoplastic circvilation ; and that the interstitial ex- 
cretory function fails before the special (renal). 

The cardiac changes are those of dilatation of right ven- 
tricle, or chiefly. They may, however, not be more than is 
answerable to the impeded circulation from the causes here 
detailed. 

The vascular form of kidney disease is witnessed in the 
granular contracted kidney, and in many such cases it is 
mixed with intratubular nephritis. The granular contracted 
kidney may anatomically be regarded as one morbid condi- 



420 DISEASES OF THE VASCULAE SYSTEM. 

tion ; clinically, the cases differ greatly, also the antecedents 
are different. 

This disease of kidney is a local expression of several 
morbid states. 

In some cases, watched for years, there has been no cardiac 
hypertrophy, no vascular disease observed, and in some the 
arterial tension is low. 

It is not yet shown to what extent this renal disease pre- 
cedes the cardio-vascular ; nor the cardiac, the renal. It is 
certain that the heart may be hypertrophied and vessels 
much diseased (arterio-capillary -fibrosis), whilst the kidneys 
are not noticeably, or but little contracted. It is equally 
certain that the kidneys may be greatly contracted and the 
heart not hypertrophied. 

In a large number of cases there is an anatomical pro- 
portion between the two morbid conditions — viz. extreme 
cardiac hypertrophy and extreme renal contraction; but this 
is the final issue, not only of the renal and the cardiac disease, 
but of other concomitant local contractions and thickenings, 
more or less disseminated throughout the body. To estimate 
the causes of the heart hypertrophy, we must regard the 
clinical events throughout, and not those only which are final. 

A more or less widespread systemic degeneration of tissues 
occurs in the moi-bid state of which granular contracted kid- 
ney is, or may be, a component, and this often before albu- 
minuria occurs. 

This is shown in many ways and degrees, by breathlessness, 
prolonged expiration, attributable to lessened pulmonary 
elasticity (emphysema), disturbed digestion, thinning of the 
voluntary muscles, looseness, and increase of fat in abdominal 
walls, bowels less regular (constipation), occasional or more 
constant occurrence of diuresis, urine variable in colour — 
from pale and clear without after-deposit to good amber 
colour with deposit of urates, these varying in amount. At 
this stage the symptoms ai'e often referred vaguely to latent 
or so-called suppressed gout ; the functions of the lungs and 
kidneys in varying degrees failing together. 

The connective substance (protoplasma) which forms 
capillary walls, adventitia, and intima of arterioles, is thick- 
ened, it becomes more compact, more fibrillated, more rigid ; 



EENAL DISEASE. 421 

and this occurs in many organs of the body ; in kidneys, 
lungs, skin, spleen, stomach, heart, retina, spinal cord, brain. 
The interstitial circulation is hindered by this widespread 
alteration in the plasma ; and consequently nutrition also. 

Anaemia and pigmentation of the skin supervene, denoting 
diminished oxidation and lower vitality of the protoplasm. 
The sense activities of skin, eye, &c., fail concomitantly with 
the respiration and muscular energy ; th.e cerebro-spinal func- 
tions become disordered, as shown by wandering pains, cramps, 
or other spasms of muscles, irritability of mind, restlessness, 
epilepsy, or delirium, &c. ; and vaso-motor function fails in 
many parts from the occurring and various inflammations. 

With the spi-ead of the fibrosis there is increasing hin- 
drance of the interstitial circulation, and increased general 
arterial tension ; whilst in the kidney the intertubular fibrosis 
additionally increases the tension in arterioles and glomeruli. 
Is it not a correct inference that the heart hypertrophy is 
much due to the widespread hindering of the circulation 
through capillaries and capillary walls, &c. ? The hyper- 
trophy occurs with this hindrance not only where there is 
much, but where there is comparatively little renal contraction. 

The causes of heart hypertrophy must be looked for far 
and wide. It cannot be forgotten that as elasticity of lung 
diminishes, the aspiratory power of chest lessens, and with 
the failing venous circulation, the circulation in the coronary 
veins is impeded, and nutrition of heart's wall perverted ; 
fat accumulates on right ventricle ; there is thickening of 
interstitial tissue of heart, and fibrosis supervenes in it. 
Thus, whilst heart muscle is hyperti'ophied in parts, it may 
be wasted in the others, until by the increasing obstruction 
in general circulation, and by the exhaustion of its nutritive 
power, it dilates. 

This course of events doos not exclude many intercui'rent 
conditions, but even probably favours them as concurrently 
leading to fibroid and other changes in the heart ; but we 
must add that the altered rhythm and mode of impulse of 
the heart in arterio-capillary-fibrosis are peculiai", and still 
call for further investigation. It remains to be determined 
whether there are not in this state conditions in the heart 
itself leading to enlargement. 



CHKONIC NEPHEITIS; 

VIZ., THE RELATION BETWEEN THE CHANGES OF CONNEC- 
TIVE TISSUE, PAEENCHYMA, BLOOD-VESSELS, 
AND HEART IN THIS DISEASE.^ 



The subject of the following remai'ks has been variously- 
designated, according to the general aspect which the kidney 
presented on the post-moi*tem table, Bright^s contracted 
kidney in the third stage — the granular kidney — the cir- 
rhotic kidney — the kidney of interstitial nephritis. Objec- 
tions might be made to each of these terms. First as to 
the use of the terms " Bright's kidney .^^ Bright's investi- 
gations had no relation to one particular form of disease of 
the kidney. 

His observations were from a clinical standpoint, and in- 
cluded all cases in which the urine was albuminous during 
life. The various forms which the kidney presented after 
death were no further classified by him than as " large and 
smooth," and " small and granular ; " and the intermediate 
condition, where the kidney was either of normal size and 
weight, or rather larger or rather smaller than normal, 
the surface being irregularly smooth or irregularly granular. 
This intermediate stage of size and surface was vaguely 
regarded as having relations on the one hand to the large 

1 * Compte-Eendu du Congres Periodique International des Sciences Medi- 
cales, 8me Session, Copenliagiie, 1884,' tome i, 1886, Section de Pathologie 
Generale et d' Anatomic Pathologique, p. 31. 



OHEONIC NEPHRITIS. 423 

white kidney from whicli in the process of time it had con- 
tracted, and on the other to the small and granular form to 
which it was supposed to be tending, and to which it would 
have reached if life had lasted. In this sense therefore the 
" Bright's kidney '* included every form of renal change, 
the whole series being characterised by albuminous urine 
during life. Again, the word " contracted " in the term 
" Bright's contracted kidney " implied, though it did not 
assert, a community of renal changes, first of swelling, and 
then of contraction. 

Erroneous as this theory is, and fully as the error of it 
has been exposed by all modern writers of authority on 
renal diseases, it is still very tenacious of life, and maintains 
itself in a degree against these attacks. The permanence of 
this narrow position is probably mainly due (i) to the habit 
of regarding the disease of the kidney as of one form and 
nature, and further as the source and starting-point of the 
several lesions associated with it throughout the system ; as 
if renal disease was always one, and had always a renal 
origin ; and as if all the morbid changes associated with it 
were its effects, and had sprung from failing renal function ; 
(2) to the assumption that albumen in the urine indicates 
one pathology ; and (3) to the occurrence post mortem in 
the several forms of renal disease, of histological changes 
which are more or less common to all the forms ; and hence 
an erroneous inference that they are of one kind, and have 
an identical pathology ; — as if one should assert that all scars 
of the skin, seeing that they have common histological char- 
acters, have one pathology. 

It would seem not to be sufficiently considered that in the 
nature of the case the morbid forms of histological expres- 
sion are limited, whatever may be their pathology ; and hence 
these lines of morbid tissue-change will have a tendency to 
approach each other as they proceed. For example, inter- 
stitial nephritis and its results in fibroid tissue and con- 
traction, may occur in kidneys in which the morbif